VlbUICAL  bUUK  a       { 

69E.59thSt..  N.Y.l 


Columbia  Winibeteitp  * 
intf)eCttpofiSeto|9orfe 

CoOese  of  ^Jpjsitians  anb  g)urBeons 


Reference  Xitirarp 


'V 


'^ 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/manualofnervousdOOspea 


A  MANUAL 
of 

NERVOUS    DISEASES 


By 
IRVING  J.  SPEAR,  M.  D. 

Professor  of  Neurology  at  the  University  of  Maryland, 
Baltimore 


WITH  172  ILLUSTRATIONS 


PHILADELPHIA   AND   LONDON 

W.   B.   SAUNDERS   COMPANY 

1916 


•7- 

Copyright,  1916,  by  W.  B.  Saunders  Company 


■-v 


PRINTED     IN     AMERICA 

PRESS    OF 

W.     B.    SAUNDERS     COMPANY 

PHILADELPHIA 


RESPECTFULLY  DEDICATED  TO   MY 
FRifiND   AND    COLLEAGUE 

PROFESSOR.    RANDOLPH    WINSLOW,  A.  M.,  M.  D.,  LL.  D. 


si> 


PREFACE 


The  preparation  of  this  volume  for  the  present  and  for  the 
future  general  practitioner  has  been  undertaken  in  the  hope 
that  I  have  been  able  to  embody  in  a  book  of  moderate  size 
the  facts  necessary  for  a  proper  understanding  of  the  anatomy, 
the  physiology,  and  the  diseases  of  the  nervous  system. 

In  my  experience  as  teacher  and  consultant  I  have  found 
that  the  student  of  medicine,  as  ^yell  as  the  general  practitioner, 
regards  the  study  of  diseases  of  the  nervous  system  as  particu- 
larly difficult.  This  false  impression  I  attribute  to  a  lack  of  a 
proper  understanding  of  the  anatomy  and  physiology  of  the 
nervous  system,  and  of  the  correct  methods  of  examining 
nervous  patients.  This  lack  of  knowledge  may  be  due  in  some 
measure  to  the  fact  that  there  is  not  at  present  available  a 
moderately  brief  exposition  limited  to  a  description  of  the 
practical  anatomy  and  physiology  of  the  nerv^ous  system. 
Such  a  description,  to  be  useful,  must  be  neither  too  brief  nor 
too  voluminous,  but  should  contain  those  facts  and  theories 
essential  to  a  clear  understanding  of  the  mechanism  of  organic 
nervous  diseases,  and  it  is  this  deficiency  that  I  have  attempted 
to  supply  in  the  first  part  of  this  volume. 

No  effort  has  been  made  completely  to  cover  the  subject  of 
neurology,  but  I  have  endeavored  to  treat  it  with  sufficient 
fulness  to  make  a  comprehension  of  the  salient  features  of 
organic  nervous  diseases  easily  possible.  This  I  hope  further 
to  have  facilitated  by  the  aid  of  illustrations  and  diagrams, 
some  of  which  are  original,  whereas  others  have  been  taken 
from  the  various  text-books  on  anatomy,  physiolog}^,  neurology, 
and  kindred  subjects,  to  which  due  credit  has  been  given. 

The  method  of  examination  laid  down  in  this  volume  appears 
to  me  to  be  that  best  suited  to  the  use  of  the  general  practitioner 

9 


lO  PREFACE 

and  the  student,  since  it  requires  no  special  apparatus  beyond 
a  galvanic  and  a  faradic  battery,  demands  very  little  special 
training,  and  is  easily  remembered. 

The  second  part  of  this  volume  is  devoted  to  a  consideration 
of  the  diseases  of  the  nervous  system.  Of  these,  the  first  to  be 
considered  are  those  that  are  readily  understood;  for  example, 
the  diseases  of  the  peripheral  nerves,  of  the  muscles,  of  the 
spinal  cord,  etc.  These  are  followed  by  the  diseases  having 
no  apparent  pathologic  basis,  the  last  to  be  considered  being 
those  diseases  due  to  perversion  of  the  functions  of  the  ductless 
glands  and  the  sympathetic  system.  Thus  by  considering 
first  the  simpler  diseases,  the  way  is  gradually  prepared  for 
placing  within  the  grasp  of  the  student  the  more  difhcult  sub- 
jects. 

I  have  endeavored  to  describe  each  disease  as  clearly  and 
briefly  as  possible,  and  to  devote  to  each  subject  the  amount  of 
space  that,  in  my  judgment,  its  importance  demanded. 

Special  attention  has  been  given  to  differential  diagnosis 
and  to  treatment,  and  I  have,  in  the  main,  confined  myself  to 
a  consideration  of  the  most  recent  accepted  facts,  avoiding, 
so  far  as  possible,  lengthy  discussions  and  theories. 

My  thanks  are  due  to  Mr.  Chandlee  for  his  painstaking  care 
in  the  making  of  many  of  the  photographs,  to  my  medical 
friends  for  kind  assistance,  and  to  my  stenographer.  Miss  Gant, 
for  her  untiring  and  intelligent  interest. 

Irving  J.  Spear. 

Baltimore,  Md., 

November,  igi6. 


CONTENTS 


ANATOMY  AND  PHYSIOLOGY  OF  THE  NERVOUS 

SYSTEM 

PAGE 

Macroscopic  Examination  of  the  Nervous  System '■ 19 

The  Neuron 23 

Anatomy  ant)  Physiology  of  a  Peripheral  Ner\-e 29 

Anatomy  and  Physiology  of  the  Spinal  Cord 32 

Structure  of  the  Spinal  Cord 40 

Blood-supply  of  the  Spinal  Cord 50 

Physiology  of  the  Spinal  Cord 53 

Anatomy  and  Physiology  of  the  Medulla  Oblongata,  Pons,  and 

Cruha ; 58 

Structure  of  the  Medulla,  Pons,  and  Cerebral  Peduncles 66 

The  Cerebelllti 73 

The  Cerebrum 81 

The  Under  Aspect  of  the  Cerebrum - 90 

Interior  of  the  Cerebrum 93 

Blood-supply  of  the  Cranial  Contents 109 

Functions  of  the  White  Substance  of  the  Cerebrum 114 

Function  of  the  Cerebral  Cortex 116 

Anatomy  and  Physiology  of  the  Cranial  Ner\tes 123 

The  Sympathetic  Nervous  System 136 

EXAMINATION   OR  THE  PATIENT 

History  and  Physical  ExAiiiNATiON 142 

Physical  Examination 145 

Examination  of  the  Ner\'ous  System 147 

Reflexes 152 

Sensory  Functions 162 

Electric  Examination 167 

Examination  of  the  Cranial  Nerves 172 

Spinal  Pl'nctltie 176 

Craniocerebral  Topography 1 78 

TI 


12  CONTENTS 

DISEASES  OF  THE   PERIPHERAL   NERVES 

PAGE 

Special  Forms  of  Traumatic  and  Inflammatory  Diseases  of  the 

Spinal  Nerves i86 

Occupation  Pareses 206 

Multiple  Neuritis  (Peripheral  Neuritis) 206 

Special  Forms  of  Multiple  Neuritis 213 

Herpes  Zoster 222 

Tumors  of  the  Nerves 225 

Neuralgia 226 

Neuralgia  of  the  Individual  Nerves 230 

DISEASES  OF  THE  MUSCULAR  SYSTEM 

Progressive  Muscular  Dystrophy 239 

Polymyositis 244 

Ischemic  Paralysis  (Volkmann's  Paralysis) 246 

Thomsen's  Disease  (Myotonia  Congenita) 247 

Periodic  Paralysis 249 

Diseases  of  the  Cranial  Nerves 250 

Diseases  of  the  First  or  Olfactory  Nerve 250 

Disorders  of  the  Second  or  Optic  Nerve 251 

Diseases  of  the  Fifth  Nerve 258 

Diseases  of  the  Seventh  or  Facial  Nerve 259 

Disorders  of  the  Eighth  or  Auditory  Nerve 263 

Diseases  of  the  Ninth  or  Glossopharyngeal  Nerve 264 

Diseases  of  the  Tenth,  Pneumogastric  or  Vagus  Nerve 265 

Diseases  of  the  Eleventh  or  Spinal  Accessory  Nerve 267 

Diseases  of  the  Twelfth  or  Hypoglossal  Nerve 267 

Diseases  of  the  Crura,  Pons,  and  Medulla 268 

Progressive  Bulbar  Paralysis 274 

DISEASES  OF  THE  SPINAL  CORD 

Acute  Anterior  Poliomyelitis 278 

Subacute    and    Chronic    Anterior    Poliomyelitis    (Progressr^ 

Spinal  Muscular  Atrophy) 286 

Amyotrophic  Lateral  Sclerosis  (Charcot's  Disease) 289 

Syringomyelia  and  Spinal  Gliosis 292 

Lateral  Sclerosis 295 

Ataxic  Paraplegia 296 

Friedreich's  Disease  (Hereditary  Ataxia) 298 

Locomotor  Ataxia  (Tabes  Dorsalis) 303 


CONTENTS  13 


PAGE 


Pressure  on  the  Spinal  Cord 319 

Fracture  and  Dislocation  of  the  Spinal  Column 325 

Tumors  of  the  Spinal  Cord 331 

Spinal  Meningitis 339 

Chronic  Meningitis 341 

Hypertrophic  Pachymeningitis 342 

Myelitis 344 

Hematomyelia 349 

Myelomalacia 353 

Senile  Paraplegia 355 

Landry's  Paralysis  (Acute  Ascending  Paralysis) 357 

Congenital  Spinal  Malformation  (Spina  Bifida;  Rachischisis)  . .  357 

DISEASES  OF  THE  BRAIN 

Pachymeningitis 359 

Pachymeningitis  Externa 359 

Pachymeningitis  Interna 359 

Meningeal  Hemorrhage 361 

Meningitis 364 

Septic  or  Secondary  IVIeningitis 365 

Epidemic  Cerebrospinal  Meningitis 368 

Tubercular  Meningitis 372 

Syphilitic  Meningitis 375 

Serous  Meningitis — Meningismus 378 

Cerebral  Anemia 380 

Cerebral  Hyperemia 382 

Rupture  or  Occlusion  of  the  Cerebral  Arteries 383 

Thrombosis  of  the  Cerebral  Sinuses  and  Veins 403 

Acute  NoN-SLT>PL"rRATRrE  Hemorrhagic  Encephalitis 408 

Infantile  Cerebral  Paralysis 412 

Hydrocephalus 422 

Abscess  of  the  Brain 426 

Cerebral  Tl^iors 433 

Paralytic  Deaientia  (General  Paresis;  General  Paralysis  of 

THE  Insane) 449 

DISEASES  OF  THE  BRAIN  AND  SPINAL  CORD 

Sythilis  of  the  Nervous  System 459 

Multiple  Sclerosis  (Disseminated  Sclerosis) 465 

Caisson  Disease ! 469 


14  CONTENTS 

DISEASES  OF  THE  NERVOUS  SYSTEM  WITHOUT 
PATHOLOGIC   FINDINGS 

PAGE 

Hysteria 471 

Neurasthenia,  or  Nervous  Exhaustion 4q_3 

psychasthenia 511 

Anxiety  Neurosis 517 

Occupation  Neurosis — Occupation  Spasms 518 

NEUROSIS  CHARACTERIZED  BY  SPASMODIC 
MUSCLE  CONTRACTIONS 

Facial  Spasm 522 

Spasms  of  the  Muscles  of  Mastication 526 

Spasmodic  Torticollis 526 

Spasmodic  Affections  of  the  Muscles  of  the  Trunk  and  Ex- 
tremities     530 

Tic  (Habit  Spasm) 530 

Chorea 533 

Chorea   Minor;    Sydenham's    Chorea   or   St..    Vitus'    Dance   and 

Chorea  Insaniens 534 

Huntington's  Chorea  (Chronic  Progressive  Hereditary  Chorea) .  .  .  543 

Chronic  Progressive  Chorea  of  Adults  and  Senile  Chorea 545 

Chorea  Accompanying  Organic  Brain  Lesions 547 

Congenital  Chorea 547 

Epidemic  Chorea 548 

Electric  Chorea 549 

Paralysis  Agitans  (Shaking  Palsy;  Parkinson's  Disease) 550 

Epilepsy  (Falling  Sickness) 557 

Myoclonus  Epilepsy  of  Unverricht 572 

Paramyoclonus  Multiplex ■ 573 

.    DISEASES  DUE  TO  PERVERSION  OF  SECRE- 
TION OF  THE  DUCTLESS  GLANDS 

Exophthalmic  Goiter  (Basedow's  or  Graves'  Disease) 575 

Myxedema — Cretinism 583 

Tetany 589 

Myasthenia  Gravis 594 

Disorders  of  the  Pituitary  Body 597 

Gigantism 603 

Acromegaly 605 

Infantilism 611 

Disorders  of  the  Pineal  Gland 615 


CONTENTS  15 

DISEASES  DUE  TO   DISTURBANCES   OF  THE 
VASOMOTOR   SYSTEM 

PAGE 

Acroparesthesia 619 

Migraine  (Hemicrania) 620 

Erythromelalgia 628 

Raynaud's  Disease  (Symmetric  Gangrene) 629 

Angioneurotic  Edema  (Acute  Circumscribed  Edema) 636 

TROPHONEUROSES 

Progressive  Facial  Hemiatrophy 638 

Scleroderma 640 

UNCLASSIFIED   DISORDERS 

Achondroplasia 642 

Tetanus ' 645 

Index 651 


MANUAL  OF  NERVOUS   DISEASES 


ANATOMY  AND  PHYSIOLOGY  OF  THE 
NERVOUS  SYSTEM 


Nervous  tissue  differs  from  other  tissue  in  that,  after  a  cer- 
tain period,  cells  do  not  increase  in  number  and  never  reproduce 
themselves.  Their  functional  capacity  and  their  durability  are 
dependent  upon  the  inherent  and  vital  energy,  the  condition  of 
the  circumambient  medium,  and  their  capacity  for  the  storage 
of  energy. 

The  nervous  system  is  composed  of  structures  situated  within 
the  cranial  cavity  and  in  projections  from  this  cavity;  the  spinal 
canal,  from  which  projections  reach  every  portion  of  the  body, 
be  it  ever  so  small  or  remote;  a  series  of  structures  with  their 
projections  situated  in  front  of  and  on  both  sides  of  the  spinal 
column,  and  connected  by  special  forms  of  nerve  tissue  to  the 
structures  within  the  spinal  canal  and  involuntary  structures  of 
the  body.  For  descriptive  purposes  these  portions  are  con- 
sidered under  the  heads  of  the  brain,  which  comprised  that  por- 
tion of  the  nervous  system  situated  within  the  cranial  cavity; 
the  cranial  nerves,  consisting  of  those  structures  connected  with 
the  brain,  and  emerging  from  various  openings  in  the  skull;  the 
spinal  cord,  that  portion  of  the  nervous  system  situated  within 
the  spinal  canal;  the  peripheral  nerves,  those  structures  that 
convey  impulses  to  and  from  the  spinal  cord ;  and  the  sympathetic 
or  autonomic  system,  consisting  of  collections  of  cells  and  fibers 
situated  on  each  side  of  and  in  front  of  the  spinal  column,  and 
connected  with  the  spinal  cord  by  the  rami  communicantes,  and 
2  17 


1 8  MANUAL   OF   NERVOUS   DISEASES 

which  communicate  with  and  are  distributed  to  every  part  of  the 
body  that  contains  smooth  muscles,  especially  the  blood-vessels, 
stomach,  intestines,  respiratory  tract,  urinary  tract,  salivary  and 
sweat-glands,  the  glands  of  the  gastro-intestinal  tract,  heart, 
esophagus,  etc.  (Fig.  i). 


Fig.  I. — Brain,  spinal  cord,  and  peripheral  nerves. 

Before  taking  up  the  study  of  the  structure  or  function  of  the 
separate  parts  of  the  nervous  system,  it  is  advisable  to  consider 
first  its  function  as  an  entity.  The  nervous  system  receives  stim- 
uli from  within  and  without  the  body.  This  constitutes  the  func- 
tion of — (i)  Irritability,  or  capacity  for  stimulation.  It  conducts 
stimuli  to  and  from  the  nervous  centers — (2)  conductivity.    It 


MACROSCOPIC   EXAMINATION    OF    THE    NERVOUS    SYSTEM     1 9 

reacts  to  stimuli  cither  consciously  or  unconsciously — (3)  con- 
scious or  automatic  response.  It  regulates  the  distribution  and 
force  of  the  response  to  stimuli;  that  is,  (4)  regulation  or  govern- 
ment. It  becomes  impressed  by  stimuli — (5)  Impressibility  or 
apprehension.  Finally  it  retains,  or  has  the  power  of  retaining 
and  storing  up,  the  memories  of  various  stimulations — (6)  mem- 
ory. 

These  various  functions  are  not  subserved  indiscriminately  by 
all  portions  of  the  nervous  system,  certain  structures  being  better 
adapted  to  carry  on  some  functions,  whereas  others  are  capable 
of  performing  certain  activities  to  better  advantage.  It  is  from 
a  study  of  the  perversion  of  these  functions,  from  embryologic 
development,  and  from  physiologic  experimentation  that  we 
have  been  able  to  discover  the  parts  played  by  many  portions  of 
the  nervous  system. 

MACROSCOPIC  EXAMINATION  OF  THE  NERVOUS  SYSTEM 

Upon  opening  the  cranial  cavity  we  see  a  large  mass,  weighing 
in  the  adult  about  1300  grams.  This  is  the  brain  and  its  pro- 
jections. The  brain  is  covered  by  the  dura  mater,  w'hich  is  a 
dense,  white  membrane  that  is  adherent  to  the  inner  surface  of 
the  skull.  This  membrane  has  several  projections — an  antero- 
posterior vertical  one,  called  the  falx  cerebri,  situated  between 
two  hemispheres  attached  anteriorly  to  the  crista  galli,  and  pos- 
teriorly and  inferiorly  to  the  tentorium  cerebelli;  a  transverse 
process,  called  the  tentorium  cerebelli,  which  roofs  the  posterior 
cranial  fossa  and  separates  the  under  surface  of  the  posterior 
cerebral  lobes  from  the  cerebellum  (Fig.  2). 

The  dura  mater  extends  down  into  the  spinal  canal,  w^here  it 
is  separated  from  the  surface  of  the  bones  by  a  layer  of  fat  and 
venous  plexuses.  The  dura  sends  tubular  prolongations  around 
the  spinal  nerves  in  their  outward  course,  these  prolongations 
being  attached  to  the  bones  in  the  intervertebral  foramina. 

The  function  of  the  dura  consists  in  helping  to  nourish  the 
cranial  bones  to  w^hich  it  is  adherent,  to  support  the  venous 
plexuses  which  it  contains,  to  sustain  the  blood-vessels,  and  to 
protect  and  support  the  nervous  elements  w^hich  it  covers  (Fig.  3) . 


20 


MANUAL   OJF   NERVOUS   DISEASES 


The  important  venous  sinuses  which  the  dura  contains  are  the 
longitudinal  sinus,  which  runs  from  before  backward,  and  is 
formed  at  the  superior  junction  of  the  falx  cerebri  with  the  dura; 
two  lateral  sinuses,  which  are  situated  at  the  posterior  junction 
of  the  dura  and  tentorium  cerebelU,  in  the  attached  margin  of  the 
latter;  the  straight  sinus,  formed  at  the  junction  of  the  falx  cerebri 


N.  ..,ii1.iui..|m 


litiiphraKiiiii  «rllw  Willi 
liininnri  i1in|>hi',ii;iiinl!i' 


Cri-la  galli 


'"^^ 


lii.-isurii  tiMltor 


Fig.  2. — Dura  mater  (Spalteholz). 


with  the  tentorium  cerebelli;  the  occipital  sinus,  situated  at  the 
posterior  attached  margin  of  the  falx  cerebelli;  the  inferior  longi- 
tudinal sinus,  contained  in  the  posterior  part  of  the  free  margin  of 
falx  cerebri.  The  torcular  herophili  is  situated  at  the  junction  of 
the  superior  longitudinal,  lateral  occipital,  and  the  straight 
sinuses.    In  addition  to  these  there  are  other  sinuses  situated  in 


MACROSCOPIC   EXAMINATION   OF    THE   NERVOUS    SYSTEM    21 

the  dura  at  the  base  of  the  brain.  These  are  the  cavernous,  the 
circular,  the  transverse,  and  the  superior  and  inferior  petrosal 
sinuses. 

Upon  removing  the  dura  we  see,  directly  covering  the  brain,  a 
very  thin,  transparent  membrane;  this  is  the  pia  arachnoid.  The 
arachnoid  is  a  delicate  membrane  that  envelops  the  brain,  lying 
between  the  pia  mater  and  the  dura  mater,  and  being  separated 
from  the  latter  by  the  subdural  space.  It  is  separated  from 
direct  contact  with  the  cerebral  substance  by  the  pia  mater.     It 


Falx  cerebri. 


Tentorium  ___/^,  /J^. 
cerebelli.        h' 


S.  petrosal  inf 


S.  petrosal  sup. 


S  occipitalis. 


Fig.  3. — ^Venous  sinuses  (Whitaker,  ''Anatomy  of  the  Brain  and  Spinal 

Cord"). 


passes  Over  the  convolutions  without  dipping  down  into  the  sulci 
between  them.  The  subarachnoid  space  is  the  interval  between 
the  arachnoid  and  the  pia  mater,  and  it  is  this  space  that  contains 
the  cerebrospinal  fluid.  The  subarachnoid  spaces  communicate 
with  the  general  ventricular  cavity  of  the  brain  by  means  of  an 
opening  in  the  inferior  boundary  of  the  fourth  ventricle  (Fig.  4) . 
The  pia  mater  is  a  vascular  nembrane,  and  derives  its  blood 
supply  from  the  internal  carotids  and  vertebral  arteries.  It  con- 
sists of  a  minute  plexus  of  blood-vessels,  bound  together  by  an 


22 


MANUAL   OF  NERVOUS   DISEASES 


extremely  fine  areolar  tissue.  The  pia  invests  the  entire  surface 
of  the  brain,  dipping  down  between  the  convolutions,  and  is 
prolonged  into  the  interior,  forming  the  velum  interpositum  and 
choroid  plexuses  of  the  fourth  ventricle.  Upon  the  surfaces  of 
the  hemispheres,  where  it  covers  the  gray  matter  of  the  convolu- 
tions, it  is  very  vascular,  giving  off  from  its  inner  surface  a  multi- 
tude of  minute  vessels  that  extend  perpendicularly  for  some  dis- 
tance into  the  cerebral  substance.     At  the  base  of  the  brain,  in 


Pia  mater. 


Dura  viater. 


\  Am,  hnoid. 


Siibdura 
space. 


l,i'yebeilii'n 


Fig.  4.— Arachnoid  and  pia  mater  (Whitaker,  "Anatomy  of  the  Brain  and 

Spinal  Cord"). 


the  region  of  the  anterior  and  posterior  perforated  spaces,  a 
number  of  long  straight  vessels  are  given  off  that  pass  through 
the  white  matter  to  reach  the  gray  substance  in  the  interior. 
On  the  cerebellum  the  membrane  is  of  more  delicate  texture,  and 
the  vessels  coming  from  its  inner  surface  are  shorter.  Upon 
the  crura  cerebri  and  pons  Varolii  the  character  of  the  pia 
undergoes  a  complete  change,  presenting  here  a  dense  fibrous 
structure  marked  only  by  slight  traces  of  vascularity. 

The  cerebrospinal  fluid  fills  the  subarachnoid  space  and  ven- 


THE    NEURON  23 

tricles.  It  is  a  clear,  limpid  fluid,  having  a  slightly  salty  taste 
and  a  feeble  alkaline  reaction.  According  to  Lassaigne,  the 
cerebrospinal  fluid  consists  of  98.5  parts  of  water,  the  remaining 
1.5  per  cent,  being  made  up  of  solids,  animal  and  saline.  The 
fluid  varies  in  quantity,  being  most  abundant  in  old  persons,  and 
is  quickly  reproduced  when  lost. 

The  brain  is  a  large  oval  mass,  the  surface  of  which  contains 
many  indentations  or  fissures.  These  include  a  deep  antero- 
posterior depression,  known  as  the  great  longitudinal  fissure,  and 
another,  situated  posteriorly,  and  called  the  transverse  fissure. 
In  addition  to  these  there  are  many  other  depressions  that  divide 
the  brain  into  smaller  parts. 

The  spinal  cord  is  a  direct  continuation  of  the  brain  into  the 
spinal  canal.  Like  the  brain,  it  is  covered  by  the  dura  and  the 
pia  arachnoid.  During  fetal  life  the  spinal  cord  extends  to  the 
lowest  part  of  the  spinal  canal.  After  burth  the  bony  structures 
grow  more  rapidly  than  the  neural  tissue,  and  the  inferior  end  of 
the  spinal  cord  gradually  retracts  from  the  lower  part  of  the 
spinal  canal,  so  that,  in  adult  life,  the  spinal  cord  extends  only  as 
far  as  the  first  or  the  second  lumbar  vertebra.  Below  this  the 
spinal  canal  is  occupied  by  the  cauda  equina,  w^hich  consists  of 
the  spinal  nerves.  On  the  anterolateral  and  the  posterolateral 
aspect  of  each  half  of  the  spinal  cord  numerous  fibers  appear 
that  coalesce  to  form  small  cords.  There  are  thirty-one  of  these 
on  each  side,  and  they  are  called  the  spinal  nerves. 

Upon  cutting  mto  the  brain  or  spinal  cord  we  perceive  that 
this  tissue  is  not  homogeneous,  but  that  the  appearance  differs  in 
various  places.  Upon  microscopic  examination,  we  find  this 
difference  to  be  due  either  to  the  absence  or  to  the  preponderance 
of  the  cells,  fibers,  blood-vessels,  and  pigment.  Investigations 
as  to  the  relative  importance,  function,  and  relationship  of  these 
various  elements  have  extended  over  many  years,  and  as  a  result 
of  these  a  theory,  known  as  the  "neuron  theory,"  has  been  pro- 
pounded. 

THE  NEURON 

"The  neuron  is  a  nerve-cell,  and  all  of  its  processes,  including 
its  protoplasmic  process  or  dendrons,  and  the  single  axis-cylinder 


24  MANUAL   OF   NERVOUS   DISEASES 

process  with  its  cone  of  origin,  its  collaterals  or  side  branches, 
and  its  terminal  arborizations. 

''The  neuronic  doctrine  is  that  the  nervous  system  consists  of 
innumerable  anatomically  independent  nervous  units  in  conti- 
guity, but  not  in  continuity.  There  are  interlacings  of  proc- 
esses, but  no  network;  the  nervous  units  are  genetically  and 
trophically  independent  cellular  organisms,  arranged  in  func- 
tionally correlated  systems  and  communities"  (Mott). 

With  this  conception  of  the  nervous  system,  it  becomes  neces- 
sary to  study,  first,  the  neuron,  its  construction  and  function; 
second,  groupings  of  these  neurons  into  systems,  communities, 
and  constellations;  and,  finally,  the  associative  interactivity  of 
the  neurons  and  collections  of  the  neurons. 

A  neuron  is  a  nerve-cell  and  all  its  processes  considered  as  a 
structural  unit.  The  cell-body  varies  ia  size  from  ssiro^  to  iio 
inch.  Neurons  vary  in  shape,  being  irregularly  spheroid,  pyram- 
idal, spindle  shaped,  or  globular.  They  give  off  one  or  more  proc- 
esses, and  may  be  classified  as  unipolar,  bipolar,  or  multipolar 
neurons.  In  most  cells  one  of  the  processes  is  continued  a  good 
distance,  and  is  generally  known  as  the  axon  and  axis-cylinder 
process.  The  other  processes  are  usually  shorter,  branch,  and 
may  be  very  tortuous;  they  are  known  as  dendrons. 

The  cell-body  is  composed  of  a  semifluid  albuminous  sub- 
stance, the  cytoplasm.  Within  this  Hes  a  nucleus,  and  within 
this  again  a  nucleolus.  The  cell-body  is  not  homogeneous,  but 
is  traversed  by  a  fine  network  of  fibrillae  that  pass  from  the 
dendrons  through  the  cell-body,  where  they  interlace,  and  out 
of  the  cell-body  with  the  axon.  Within  this  network  there  are 
fine  granular  bodies  known  as  Nissl's  bodies,  or  chromophile 
substance.  These  bodies  are  arranged  in  quite  a  definite  manner 
around  the  nucleus. 

The  dendrons  are  branching  protoplasmic  substances  that 
resemble  the  cell-body  in  structure.  As  they  extend  they  divide 
and  subdivide,  resembling  in  appearance  the  root  of  a  tree. 
In  some  cells  they  are  very  numerous  and  terminate  in  fine 
fibrils.  They  may  also  present  on  their  surface  small  nodules 
called  gemmules,  or  buds.  Within  the  dendrons  are  fine  fibrils 
that  join  the  fibrillar  network  of  the  cell-body  (Fig.  5). 


THE   NEURON  25 

The  axon  or  axis-cylinder  process  is  always  single,  arising  from 


Fig.  5. — Diagram  of  a  neuron  motor  from  the  ventral  column  of  gray 
matter  in  the  spinal  cord.  The  cell-body,  dendrites,  axon,  collateral  branches, 
and  terminal  arborizations  in  muscle  are  all  seen  to  be  parts  of  a  single 
cell  and  together  constitute  the  neuron:  ah.  Axon  hillock  free  from  chromo- 
philic  bodies;  a.v,  axon;  c,  cytoplasm  of  cell-body  containing  chromophilic 
bodies,  neurofibrils,  and  other  constituents  of  protoplasm;  d,  dendrites;  w, 
myelin  (medullary)  sheath;  m',  striated  muscle-fiber;  »,  nucleus;  n',  nucleo- 
lus; 7iR,  node  of  Ranvier  where  the  axon  divides;  sf,  collateral  branch;  si, 
neurilemma  (not  a  part  of  the  neuron) ;  tel,  motor  end-plate.     (.Alter  Barker.) 

a  cone-like  projection  of  the  cell-body  that  contains  little  or  no 
chromophile  substance,  but  that  does  contain  many  fine  fibrils. 


26  MANUAL   OF   NERVOUS   DISEASES 

In  the  central  nervous  system  the  axon  gives  off  numerous  fine 
collateral  branches  at  right  angles  to  its  course,  but  after  it 
emerges  from  the  central  nervous  system  it  does  not  branch  until 
it  reaches  its  termination, where  it  ends  in  a  plexus,  muscle-plates, 
tuft,  or  tassel.  The  axon  is  made  up  of  many  fine  fibrils  that  are 
continuous  with  those  of  the  cell-body  and  the  dendrons.  When 
the  axons  leave  the  gray  matter  they  are  insulated  from  one  an- 
other by  receiving  a  fatty  coating  or  medullary  sheath,  which  is 
held  in  place  by  a  thin  membrane;  this  they  lose  again  at  their 
termination. 

A  second  type  of  cells  develops  outside  of  the  central  nervous 
system,  in  the  ganglia,  on  the  posterior  roots;  they  are  bipolar, 
but  during  development  the  two  processes  approach  each  other 
and  then  appear  to  be  fused  for  a  short  distance.  Thus  in  the 
adult,  this  type  of  neuron  is  pear  shaped,  and  appears  to  have  but 
a  single  process,  which  diverges  into  two  parts,  the  one  formmg 
the  sensory  portion  of  the  peripheral  nerve  and  terminating  in 
brush-like  expansions  on  the  skin,  in  plexuses,  and  bulbs  of 
Krause,  or  tactile  corpuscles;  the  other  enters  the  spinal  cord 
through  the  posterior  roots  and  also  terminates  in  brush-like 
expansions. 

From  what  has  been  said  we  see  that  a  neuron  is  made  up  of 
a  cell-body,  with  the  nucleus,  nucleolus,  reticulated  fibrillae, 
chromophile  substance,  and  a  number  of  processes,  one  of  which 
is  called  an  axon,  the  others  being  termed  dendrons. 

Both  axons  and  dendrons  are  made  up  of  a  number  of  fibrillae 
surrounded  by  myelin,  this  in  turn  being  invested  in  a  sheath. 
Although  the  fibrils  are  continuous,  we  find  that  the  myelin 
sheath  consists  of  a  series  of  short  tubes,  from  i  to  1.5  mm. 
long.  The  point  of  junction  of  the  two  tubes  is  indicated  by 
a  constriction  known  as  the  node  of  Ranvier.  The  external 
sheath,  called  the  sheath  of  Schwann,  is  a  connective-tissue 
structure,  and  in  the  adult  fiber  is  continuous  over  the  node  of 
Ranvier.  The  sheath  of  Schwann  is  not  present  in  the  central 
nervous  system.  Nerve-fibers  lose  the  myelin  substance  and 
also  the  sheath  of  Schw^ann  at  their  peripheral  termination. 

A  nerve-fiber  is  made  up  of  central  conducting  strands,  which 
are  insulated  by  a  series  of  cylinders  placed  end  to  end,  myelin 


I »/ 


THE    NEURON 


27 


substance,  and  covered  by  the  sheath  of  Schwann.  Such  fibers 
are  called  medullated  nerve-fibers,  and  constitute  the  principal 
part  of  the  peripheral  nervous  system.  The  non-meduUated 
fibers,  or  fibers  of  Remak,  are  made  up  only  of  fibrils  surrounded 
by  a  neurilemma  sheath.  They  present  a  grayish  appearance. 
The  sympathetic  and  the  olfactory  nerves  consist  chiefly  of  non- 
medullated  nerve-fibers  (Fig.  6). 


\| 


i^Nucleus 
-Neuro  -fi  b  rilla 


'^Node  of  Ban  VI  er 

-Nucleus  of  Neurilemma 
Neurofibril  la  of  Axon 

t^chmidf- 1  antermann 
incisions 


Myelin  substance  or 
Sheaih  of  Schwann 

Neurilemma 
B 

Fig.  6. — Longitudinal   section:    A,  Non-medullatecl  fiber   from   the  s>Tn- 
pathetic  system;  B,  medullated  fiber.     (Diagrammatic.) 


Function  of  the  Cell. — Waller,  Tiircke,  von  Gudden,  and  many 
other  observers  have  shown  that  whenever  a  process  is  separated 
from  its  cell-body  the  process  degenerates.  On  this  fact  was 
formulated  the  Wallerian  law  of  degeneration,  which  is  the  basis 
of  much  experimental  and  pathologic  investigation  regarding  the 
course  of  nerve- tracts  and  the  origin  of  nerve-fibers.  This  law 
holds  that  whenever  a  cell  process  is  separated  from  its  cell-body, 
the  distal  portion  of  the  separated  process  degenerates  through- 
out its  extent  and  becomes  functionless.  Changes  also  take 
place  in  the  proximal  portion  for  a  short  distance,  and  minor 


28  MANUAL   OF   NERVOUS   DISEASES 

changes  occur  in  the  cell-body.  This  degenerative  process 
begins  almost  immediately  or  within  a  few  hours,  and  may  be 
demonstrated  microscopically. 

The  Wallerian  law  proves  that  one  of  the  functions  of  the  cell 
is  to  provide  nourishment  for  the  processes  connected  therewith. 
This  is  further  proved  by  the  fact  that  if  a  cell  is  destroyed, 
either  experimentally  or  as  the  result  of  disease,  all  its  processes 
degenerate  throughout  their  extent  and  are  rendered  functionless. 
It  has  also  been  shown  experimentally,  and  as  the  result  of 
clinical  investigation,  that  so  long  as  the  cell  is  intact  and  other 
certain  conditions  are  present,  the  proximal  portion  of  the  divided 
process  begins  to  grow  and  send  out  fibrillse,  which,  under  proper 
conditions,  will  cause  regeneration  of  the  distal  portion  of  the 
divided  process.  Nerve-fibers,  as  we  have  seen,  are  capable  of 
conducting  impulses  in  both  directions,  but  physiologically  they 
conduct  them  only  in  one  way.  There  must,  therefore,  be  some 
activity  of  the  cell-body  that  permits  impulses  to  travel  in  only 
one  direction.  Moreover,  the  cell-body  of  the  neuron  must  have 
a  still  higher  and  more  important  function,  that  is,  the  power  of 
selective  and  discriminating  activity.  It  must  be  an  inherent 
function  of  the  nerve-cell  to  be  able  not  only  to  determine  the 
direction  of  the  impulse,  but  also  to  direct  impulses  to  their 
proper  destination. 

It  will  be  seen,  therefore,  that  the  cell-body  possesses  the  follow- 
ing functions:  It  nourishes  its  process,  that  is,  it  is  the  trophic 
center,  and,  under  proper  conditions,  it  causes  its  process  to 
regenerate;  it  governs  the  direction  of  impulses;  it  determines  the 
destination  of  and  directs  all  outgoing  impulses.  How  this 
determination  of  the  destination  and  the  direction  of  the  impulse 
to  its  proper  station  are  accomplished  is  a  question  that  is  inex- 
tricably bound  up  with  the  problem  of  life  itself. 

The  mode  of  transmission  of  stimuli  from  one  cell  to  another 
in  the  human  being  is  still  a  disputed  question.  Whether  the 
processes  are  capable  of  ameboid  movement  and  can  thus  pro- 
duce contact  when  desired,  as  is  believed  by  some;  whether 
a  physiologic  change  occurs  in  the  material  through  synapses 
that  separate  the  process  of  one  cell  from  the  processes  or  cell- 
body  of  another,  thus  allowing  the  transmission  of  the  impulse 


ANATOMY   AND   PHYSIOLOGY    OF    A   PERIPHERAL    NERVE     29 

from  neurofibrils  of  one  cell  to  those  of  another — these  are  still 
moot  points. 

If  one  understands  the  function  of  a  single  neuron,  further 
comprehension  of  the  activities  of  the  nervous  system  resolves 
itself  into  a  knowledge  of  the  grouping  together  of  numbers  of 
neurons,  the  effect  of  one  transmitting  its  activity  to  another  or 
to  others,  and  the  result  of  this  activity,  as  expressed  in  one  of 
the  physiologic  functions  of  the  body.  Thus  disease  of  the 
nervous  system  is  an  abnormal  functioning  of  one  or  more  neu- 
rons, expressed  in  abnormal  reaction. 

ANATOMY  AND   PHYSIOLOGY   OF  A  PERIPHERAL 

NERVE 

There  is  no  histologic  difference  between  a  sensory,  a  motor, 
and  a  mixed  nerve.     The  only  difference  between  these  varieties 


Epineunum 

Perineurium  enclosing  the  funiculi 
or  bundles  ofneri/e  fibers 


Endoneuri  um 

Nerve  fiber  cut  transversely 


B 


Fig.  7. — A,  Transverse  section  of  a  nerve.  B,  Longitudinal  section  of  a 
nerve:  i,  Primitive  sheath  or  neurilemma;  2,  medullary  sheath  or  white 
substance  of  Schwann;  3,  nucleus;  4,  axilemma  (of  Kuhne);  5,  neuroplasm; 
6,  node  (of  Ranvier);  7,  fibrillae  (of  Schultze). 


30 


MANUAL   OF   NERVOUS   DISEASES 


is  that  the  motor  nerves  have  a  special  form  of  ending,  which  will 
be  described  later,  whereas  the  sensory  nerves  have  a  special 
form  of  origin,  which  will  also  be  discussed  further  on. 


Fig.  8. — Showing  some  varieties  of  peripheral  terminations  of  afferent 
neurons  (or  "peripheral  nerve  beginnings."):  A,  Terminal  fibrillae  in  epithe- 
lium (after  Retzius);  B,  tactile  corpuscle  (Meissner's,  after  Dogiel);  C,  bul- 
bous corpuscle  (Krause's,  after  Dogiel);  D,  lamellated  corpuscle  (Pacini's, 
after  Dogiel,  Sala,  and  others);  E,  genital  nerve  corpuscle  from  human 
glans  penis  (after  Dogiel):  a,  axon;  t,  telodendria. 


A  peripheral  nerve  is  made  up  of  a  great  number  of  conducting 
strands  that  are  separated  from  one  another  by  specialized  sub- 
stances.    On  its  surface  a  peripheral  nerve  presents  a  white  and 


ANATOMY  AND  PHYSIOLOGY  OF  A  PERIPHERAL  NERVE  3 1 

glistening  sheath,  called  the  epineurium.  Upon  cross-section  of 
a  nerve  and  examination  under  a  microscope  it  will  be  seen  that 
the  ner^'e  is  divided  into  numerous  lari^e  bundles  or  fibers  that 
are  separated  from  one  another  by  the  perineurium.  This  peri- 
neurium supports  the  small  blood-vessels  of  the  nerves.  The 
large  bundles  are  divided  in  turn  into  smaller  bundles,  which  are 
separated  from  one  another  and  surrounded  by  endoneurium. 


Fig.  9. — Diagram  of  motor  nerve-endings:  A,  Striated  muscle;  B,  cardiac 
muscle;  C,  unstriated  muscle:  a,  axon;  t,  telodendria.  (After  Huber,  Bohm 
and  Davidoff,  and  others.) 

These  smaller  bundles  are  seen  to  consist  of  numerous  axis- 
cylinder  processes  or  axons,  each  of  which  is  surrounded  by  the 
sheath  of  Schwann  and  the  myelin  substance.  When  one  of 
these  axis-cylinder  processes  is  examined  under  high  magnifica- 
tion, it  is  seen  to  consist  of  numerous  fibrils  that  are  held  together 
by  a  cement-like  substance  called  the  neurilemma  (Fig.  7). 

Motor  nerves  terminate  in  muscle  plates,  in  plexuses,  or  in 
specialized  endings;  sensory  nerves  originate  at  the  tactile  cor- 


32  MANUAL   OF   NERVOUS   DISEASES 

puscles  in  the  bulbs  of  Krause,  plexuses,  tufts,  or  in  specialized 
endings  (Figs.  8,  9). 

Nerve-fibers  are  capable  of  conducting  stimuli  in  both  direc- 
tions, and  transmit  these  at  the  rate  of  about  90  feet  a  second. 
Although,  as  stated,  nerve-fibers  are  capable  of  conducting 
stimuli  in  both  directions,  yet  physiologically  a  normal  stimulus 
is  transmitted  only  in  one  direction:  in  the  axis-cylinder  proc- 
esses, away  from  the  cell;  in  the  dendritic  processes,  toward 
the  cell. 

ANATOMY  AND  PHYSIOLOGY  OF  THE  SPINAL  CORD 

The  spinal  cord  is  that  portion  of  the  nervous  system  contained 
in  the  spinal  canal  of  the  vertebral  column.  It  extends  from  the 
foramen  magnum  to  the  coccyx.  It  is  cylindric  in  shape  and 
flattened  anteroposteriorly.  It  has  two  enlargements — one 
above,  known  as  the  cervical  enlargement,  and  one  below,  known 
as  the  lumbar  enlargement.  The  average  diameter  of  the  spinal 
cord  in  the  adult  is  about  J  inch  anteroposteriorly,  and  slightly 
greater  laterally.  It  is  covered  by  the  dura  mater,  which  is 
continuous  with  that  which  invests  the  brain,  is  not  adherent  to 
the  bony  w^alls  of  the  vertebrae,  but  is  separated  from  them  by 
loose  areolar  tissue  and  a  plexus  of  veins.  The  cord  extends  as 
low  as  the  third  sacral  vertebra;  beyond  this  it  is  continued  as  a 
slender  cord  to  the  back  of  the  coccyx,  where  it  blends  with  the 
periosteum.  The  sheath  is  much  larger  than  is  necessary  for 
its  contents.  Its  inner  surface  is  smooth,  and  on  each  side  open- 
ings may  be  seen  that  transmit  the  two  roots  of  the  correspond- 
ing spinal  segment,  the  dura  being  continued  in  the  form  of  a 
tubular  prolongation  on  them  as  they  pass  through  these  open- 
ings (Figs.  10,  11). 

On  opening  the  lower  part  of  the  dura  mater  the  roots  of  the 
lumbar  and  sacral  nerves  are  brought  into  view.  These  roots, 
taken  together,  form  the  cauda  equina.  The  dura  is  made  up  of 
.fibrous  and  elastic  tissue,  the  internal  surface  being  covered  by 
endothelial  cells.  It  is  but  sparingly  supplied  with  vessels  and 
has  few  nerves. 

The  arachnoid  is  a  thin,  delicate  membrane  that  invests  the 


ANATOMY   AND   PHYSIOLOGY   OF    THE   SPINAL    CORD     33 

surface  of  the  cord.  It  is  connected  with  the  pia  by  slender 
connective-tissue  filaments.  It  is  continuous  with  the  cerebral 
arachnoid,  and  is  reflected  in  the  form  of  a  sheath  over  the  va- 
rious nervTS  as  they  pass  outward  to  the  intervertebral  foramen. 
The  outer  surface  of  the  arachnoid  is  in  contact  with  the  inner 
surface  of  the  dura,  and  in  places  is  connected  with  it  by  means 


Fig.  10. — Cauda  equina  (Fleming,  in  Allbutt's  "System  of  Medicine"). 


of  connective- tissue  trabeculae.      Especially  does  this  occur  at 
its  posterior  portion,  where  the  fasciae  dentatae  are  formed. 

The  inner  surface  is  separated  from  the  pia  by  a  considerable 
space,  called  the  subarachnoid  space.  This  space  is  largest  in  the 
lower  part  of  the  spinal  canal,  where  it  incloses  the  cauda  equina. 
Superiorly  it  is  continuous  with  the  cranial  subarachnoid  space, 
and  communicates  with  the  general  ventricular  cavity  of  the 


34 


MANUAL   OF   NERVOUS   DISEASES 


Ki«;    I. 


I'fiiuiit  iili  cerehrx 


Subdural 


MvrlrHrfphnlnn 


Medulla 


\     I    (,N. 


I'ars  ct-rtrirciU.r    .,^4    ^s^, 

f  ]  ^^  7 


'  -ii 


/*««  lumhalis.     £jL,  V^ 


^     ^       4 


Pars  sacralis.  -^^-^X       I    -> 


(  onuj  medullar 


!    Filnm  terminaU 


'     1/    K      ' 


fdutix  fu)\i  ..     (   , 


Spina/  Cord.    -Membranes 


spinal  tifn'r 


Fig.  II. — Membranes  of  the  spinal  cord  (Whitaker,  "Anatomy  of  the  Brain 

and  Spinal  Cord").. 


ANATOMY    AND    PHYSIOLOGY    OF    THE    SPINAL   CORD      35 

brain  by  means  of  openings  in  the  pia  mater  at  the  inferior 
boundary  of  the  fourth  ventricle  by  the  foramina  of  Magendie 
and  of  Retzius. 

The  subarachnoid  space  is  filled  with  an  abundant  serous 
secretion,  the  cerebrospinal  fluid,  and  allows  a  certain  amount  of 
motion  to  the  spinal  cord. 

The  pia  mater  covers  the  entire  surface  of  the  cord,  to  which 
it  is  intimately  adherent,  and  sends  processes  downward  into  the 
anterior  fissure.  It  forms  a  sheath  for  each  of  the  filaments  of 
the  spinal  nerves,  and  invests  the  nerves  themselves.  It  con- 
tains a  number  of  lymphatic  spaces  that  communicate  with  the 
subarachnoid  space.  The  pia  is  well  supplied  with  blood-vessels, 
w^hich  are  inclosed  in  perivascular  sheaths  derived  from  its  inner 
layer.     It  receives  its  nerve  supply  from  the  sympathetic  plexus. 

The  spinal  cord  is  about  17  or  18  inches  long,  and  weighs 
about  one  and  one-half  ounces.  It  does  not  nearly  fill  the  verte- 
bral canal.  In  the  adult  it  occupies  the  upper  two-thirds  of  the 
canal,  extending  from  the  upper  border  of  the  axis,  where  it  is 
continuous  with  the  medulla,  to  the  lower  border  of  the  body  of 
the  first  lumbar  vertebra,  where  it  is  terminated  in  a  slender 
filament  of  gray  substance,  which  is  continued  for  some  distance 
as  the  filum  terminale.  In  the  three-months'  fetus  it  extends  to 
the  bottom  of  the  sacral  canal,  but  as  the  fetus  grows  older  it 
gradually  recedes  from  below.  This  is  due  to  the  fact  that  the 
grow^th  of  the  bones  comprising  the  canal  is  proportionately  more 
rapid  than  that  of  the  cord.  At  birth  the  cord  extends  as  far  as 
the  third  lumbar  vertebra  (Fig.  12). 

The  cervical  enlargement  extends  from  the  third  cervical  to 

the  first  or  second  dorsal  vertebra.     Its  greatest  diameter  is 

,  laterally.     The  lumbar  enlargement  is  situated  opposite  the  last 

two  or  three  dorsal   vertebrae,  and  has  its  greatest  diameter 

anteroposteriorly. 

The  cord  presents  on  its  anterior  surface,  in  the  midline,  a 
longitudinal  fissure, — the  anterior  median  fissure, — and  on  its 
posterior  aspect  another  fissure,  not  so  well  marked  as  this — the 
posterior  median  fissure  or  sulcus.  The  anterior  median  fissure 
extends  into  the  cord  for  about  one- third  of  its  thickness,  and 
contains  a  prolongation  of  the  pia  mater.     Its  floor  is  formed  by 


Fig.  12. — Spinal  cord  in  the  vertebral  canal  (Feigel). 


36 


ANATOMY    AND    PHYSIOLOGY    OF    THE    SPINAL    CORD      37 

the  anterior  white  commissure,  and  it  is  perforated  by  numerous 
blood-vessels  passing  into  the  center  of  the  cord.  The  posterior 
median  fissure  is  not  a  depression  or  opening,  but  is  a  connective- 
tissue  septum  that  divides  the  posterior  part  of  the  cord  into 
halves  and  supports  the  blood-vessels.  It  extends  into  the  cord 
for  one-half  its  depth  (Fig.  13). 

The  surface  of  the  cord  is  further  divided  into  columns  by  the 
line  of  emergence  of  the  anterior  roots  and  the  depression  of 


Fig.   13. — Cross-section  of   spinal   cord,  showing   cells,  fibers,  and   tracts 

(diagrammatic) . 


entrance  of  the  posterior  roots — anterior  columns,  lateral  col- 
umns, and  posterior  columns  (Fig.  14). 

On  either  side  of  the  cord,  at  the  junction  of  the  anterior  third 
with  the  posterior  two-thirds,  and  at  the  junction  of  the  poste- 
rior third  with  the  anterior  two-thirds,  there  emerge  small  fibers. 
Those  that  emerge  at  the  anterolateral  aspect  coalesce  at  the 
various  levels  of  the  cord  to  form  a  single  nerve,  each  one  being 
called  an  anterior  nerve-root.  This  occurs  also  in  the  postero- 
lateral aspect,  each  being  here  called  a  posterior  nerve-root. 
There  are  31  anterior  and  31  posterior  nerve-roots  on  each  side 
of  the  cord. 


38 


MANUAL   OF   NERVOUS   DISEASES 


A  segment  of  the  spinal  cord  is  made  up  of  white  and  of  gray 
matter,  of  blood-vessels,  and  of  a  pair  of  spinal  nerves  that 
pass  to  a  definite  part  of  the  body.  Each  segment  is  joined 
to  other  segments  by  means  of  nerve-tracts.  Each  spinal  nerve 
is  made  up  of  two  roots — the  sensory  and  the  motor.  On  the 
posterior  root,  within  the  intervertebral  foramen,  just  before  it 
is  joined  by  the  anterior  root,  there  is  an  enlargement  called  a 
posterior  root  ganglion. 

Posterior  Septum 

•^r  _£ — Posterior  Column 

Posterior  Roots 


interior  Median  fissure 

Anterior  Column 


Anterior  Roots 


Fig.  14. — Showing  columns  of  cord,  anterior  and  posterior  roots,  etc.  (dia- 
grammatic) . 


The  anterior  and  posterior  roots  on  each  side  from  a  spinal 
segment  coalesce  in  the  intervertebral  foramina.  From  this 
point  outward  they  run  their  course  as  a  single  mixed  nerve. 

In  the  cervical,  lumbar,  and  sacral  regions  the  spinal  nerves 
intermingle  to  form  the  cervical,  brachial,  lumbar,  and  sacral 
plexuses.  There  are  eight  (8)  cervical  segments,  twelve  (12) 
dorsal  segments,  five  (5)  lumbar  segments,  five  (5)  sacral  seg- 
ments, and  one  (i)  coccygeal  segment. 


ANATOMY    AND    PHYSIOLOGY    OF    THE    SPINAL    CORD     39 


__N.fo Rectus  lateralis 

_  N-  To  HecTus  antic.  min»r 
/4nastom»3  is  wi  th  Hypoyloisal 

finajtomosii  with  Pmamogasn-ie 

f^.to  ffecfui  Of  Tie  major 

\  _  _  N  to  mastoid  region 

Creaf  CU/riCu/ar  rr 

-  -  Transverse  CervicaJ  »■ 

-.l\N.to  TrapeJ-ius.^i^-Scap.  tffhomboid. 

_. Supra  Clavicular  n. 

^jjpra.  OcromiaJ  n 
-  /Wrenicrt 

IV.  fo  legator  an^  .5cap. 

-A/,  to  Rhomboid 
SubSccLfifi'tr  n 
Sub  cla  vicularn 

M  fo  Pectoral I'i  rnajtr 

Circumflex  n 

.  Musculo  -  Cutaneous  IT- 
Median   n. 
-Faolial  n 
Ulnar  rr- 

./nTernal  cutaneous  n 
t3maJI  int.  Cutaneous n- 


Jlio-hypoga^tric  tt- 
Ilio-inguinail  tj- 

.External  cutaneous  //• 
.Gen'ito-  cruraJ  n. 

.  /Interior  CruraJ n. 
Obturator  n. 


^/Jo  levator  anj  • 
N.  to  oVfurafor  int 
N-  To  SphincTerani.. 


Superior  CluteaL  n. 


l^  fo  Pyri  formis 

/^to  Gemellus  Simper 

_: i^.to  Gemellus  inf- 

/v.  to  Quadrcdus 

Sma//  Sciati  c  rt- 

Sciatic  n 


Pig   1 5. —Relation  of  the  spinal  segments  and  nen-es  to  the  bodies  and 
spines  of  the  vertebra.     (After  Butler.) 


Owing  to  the  fact  that  the  spinal  cord  itself  is  not  so  long  as 
the  spinal  canal,  the  various  segments  of  the  cord  in  the  lower 


40  MANUAL   OF  NERVOUS   DISEASES 

cervical,  dorsal,  and  lumbar  region  are  not  directly  opposite  the 
corresponding  vertebrae  of  the  spinal  column. 

Chippault  has  given  us  a  practical  set  of  rules  for  determining 
the  relations  of  the  segments  to  the  spinous  processes  of  the 
vertebrae.  He  says:  "In  the  cervical  region  add  one  (i)  to  the 
number  of  vertebrae,  and  this  will  give  the  segments  opposite. 
In  the  upper  dorsal  region  add  two  (2) ;  from  the  sixth  to  the 
eleventh  dorsal  vertebrae  add  three  (3) .  The  low^er  part  of  the 
eleventh  dorsal  spinous  process  is  opposite  the  three  (3)  lower 
lumbar  segments.  The  twelfth  dorsal  spinous  process  and  the 
space  below  it  are  opposite  the  sacral  segments."  The  spinal 
cord  ends  opposite  the  first  lumbar  vertebra  or  opposite  the  car- 
tilage in  the  space  above  it  (Fig.  15). 

STRUCTURE    OF   THE    SPINAL   CORD 

If  a  transverse  section  is  made  through  the  spinal  cord,  it  wdll 
be  found  to  consist  of  white  and  of  gray  matter.  The  white 
matter  is  situated  externally,  surrounding  the  gray  matter.  The 
relative  proportion  of  gray  and  of  white  matter  varies  in  different 
regions  of  the  cord  (Fig.  16). 

Upon  cross-section  the  gray  substance  presents  two  crescentic 
masses,  one  situated  in  each  lateral  half  of  the  cord,  united  by  a 
transverse  band  of  gray  matter.  Each  crescentic  mass  presents, 
for  purposes  of  description,  an  anterior  and  a  posterior  portion, 
called  the  anterior  and  the  posterior  horn,  and  in  the  cervical 
region  a  lateral  extension  on  the  level  with  the  gray  connecting 
band,  called  the  lateral  horn.  The  gray  connectmg  band,  which 
is  called  the  gray  commissure,  contains  a  small  central  canal. 

The  posterior  horn  approaches  close  to,  but  does  not  touch, 
the  surface  of  the  cord  at  the  posterolateral  fissure,  where  the 
posterior  roots  enter  the  cord.  The  anterior  horn  does  not 
approach  the  surface  of  the  cord,  but  is  separated  from  it  by  a 
definite  layer  of  white  matter. 

Description  of  the  Gray  Substance. — ^The  gray  substance  is 
made  up  of  nerve-fibers  of  variable  length,  but  of  smaller  average 
diameter  than  those  of  the  white  substance,  of  nerve-cells  of 
various  sizes  and  shapes,  of  neuroglia,  and  of  blood-vessels. 


STRUCTURE    OF    THE    SPINAL    CORD 


41 


Cervical 


Thoraci 


Lumbar 


Fig.  16. — Transverse  sections  of  spinal  cord:  A,  Direct  pyramidal;  B, 
ventral  ground-bundle;  C,  Spitzka-Lissauer's;  D,  ventrolateral  ground  bun- 
dle; E,  Gowers';  F,  crossed  pyramidal;  G,  spinocerebellar;  H,  Burdach's;  /, 
Schutze's  comma;  /,  GoU's.     (Gray's  "Anatomy.") 

The  nerve-cells  are  of  two  kinds,  large  and  small.     The  ante- 
rior horns  contain  groups  of  large  cells,  occupying  a  more  or  less 


42  MANUAL   or   NERVOUS  DISEASES 

constant  position,  and  arranged  in  the  medial,  anterior,  and 
lateral  portions.  The  cells  situated  in  the  gray  commissure, 
around  the  central  canal,  and  in  the  posterior  horns,  are,  as  a 
rule,  small  and  irregular  in  shape.  On  the  inner  aspect  of  the 
posterior  horn,  near  the  gray  commissure,  extending  from  the 
seventh  cervical  to  the  third  lumbar  segment,  are  groups  of  cells 
arranged  in  a  tract  called  Clarke's  column  or  vesicular  column. 

The  posterior  horn  consists  of  two  parts,  the  caput  cornu, 
surrounding  the  gelatinous  substance,  and  the  cervix  cornu, 
which  is  the  constricted  portion,  and  connects  the  posterior  horns 
with  the  remainder  of  the  gray  substance. 

The  anterior  horns  are  best  developed  in  the  cervical  and  lum- 
bar regions,  where  they  give  origin  to  the  nerves  of  the  extremi- 
ties, and  contain  more  or  less  well-marked  and  constantly  situ- 
ated groups  of  large  cells. 

Extending  from  the  gray  matter  opposite  the  gray  commissure 
in  the  cervical  and  upper  dorsal  region  is  a  lateral  extension  of 
gray  matter  called  the  lateral  horn  or  cornu. 

The  gray  or  posterior  commissure  is  that  portion  of  the  gray 
substance  which  connects  the  two  crescentic  masses.  It  is  sepa- 
rated from  the  bottom  of  the  anterior  median  fissure  by  the 
anterior  white  commissure.  Extending  through  the  gray  com- 
missure and  running  the  entire  length  of  the  cord  is  a  minute 
canal  which  is  barely  perceptible,  in  the  human  being,  to  the 
naked  eye.  This  canal  is  called  the  central  canal,  and  opens  into 
the  fourth  ventricle.  Grouped  irregularly  around  this  canal 
throughout  its  entire  length  are  numerous  small  cells. 

Neurogliar  tissue  is  made  up  of  small,  stellate  or  branched 
cells  called  glia-cells,  and  of  a  network  of  very  delicate  fibrill^e. 
This  tissue  forms  the  ground-substance  in  which  nerve-cells, 
their  processes,  and  blood-vessels  are  embedded.  A  consider- 
able amount  of  this  tissue  is  accumulated  on  the  surface  of  the 
cord  beneath  the  pia,  around  the  central  canal,  and  in  the  pos- 
terior part  of  the  posterior  horn. 

The  White  Substance. — This  is  made  up  of  longitudinal  fibers 
arranged  in  columns,  of  oblique  and  transverse  fibers. 

The  White  Commissures. — The  anterior  white  commissure, 
situated  in  front  of  the  gray  commissure,  and  separating  it  from 


STRUCTURE    OF    THE    SPINAL    CORD 


43 


the  anterior  median  fissure,  is  made  up  of  fibers  that  cross  from 
the  anterior  columns  of  one  side  to  end  in  the  anterior  horns  of 
the  opposite  side.  The  posterior  white  commissure  is  a  small 
band  of  transverse  fibers  situated  immediately  posterior  to  the 
gray  commissure. 

The  oblique  fibers  are  present  at  all  levels  of  the  cord.  They 
are  the  fibers  that  enter  or  leave  the  longitudinal  columns,  to 
terminate  or  originate  in  the  gray  matter.     The  longitudinal 


Roots 


Posterior  Fools 


Muscle  5ense  '        Tactile  Sense 


Fig.  17. — I,  Direct  pyramidal  tract;  2,  anterolateral  ground-bundle;  3, 
Gowers'  tract;  4,  direct  cerebellar  tract;  5,  crossed  pyramidal  tract;  6, 
Burdach's;  7,  Goll's;  8,  Lissauer's  tract;  9,  comma  tract;  I,  anterior  horn 
cells,  II,  cells  around  central  canal;  III,  cells  at  anterior  part  of  posterior 
horn;  IV,  Clarke's  column  of  cells.     Diagrammatic. 


fibers  pursue  a  longer  or  shorter  course,  and  either  originate  or 
terminate  in  the  gray  matter  (Figs.  17  and  19). 

Anterior  Roots. — The  axons  of  the  large  cells  in  the  anterior 
horn  emerge  through  the  anterior  horn,  pierce  the  anterior  col- 
umn, issue  from  the  spinal  cord  as  the  anterior  roots,  and  form 
the  motor  portion  of  the  peripheral  ners^e. 

Processes  from  the  cells  around  the  central  canal  emerge  with 


44 


MANUAL   OF   NERVOtTS   DISEASES 


Superficial  and 
deep  reflex-es 


tjup'incJor  a/td 
biceps  jerK. 

Elbow  and. 
i^rlst  jerH. 

iScapuiar.- 
Palmar.  ■ 


AUTOMATIC 
CENTERS 


Epi^astr 


Abdominal 


Cremasteric.. 
KneejerMr 


Gluteal: 

/Int^tejerk  ^ 
a/idclonus 


Plantar, 


Cilio-Jpinal 


4 


6 


Vasomotor 


(erection,  ejaculatron') 


Bladder  cuicL 
Pactum 


Fig.  1 8. — Location  of  centers  of  spinal  cord. 


the  anterior  and  the  posterior  roots.     Processes  of  cells  in  the 
anterior  part  of  the  posterior  horn  cross  the  cord  in  the  gray 


STRUCTURE   OF    THE    SPINAL    CORD  45 

commissure,  and  ascend  in  the  anterolateral  ground-bundle,  or, 
without  crossing,  ascend  in  the  anterolateral  ground-bundle  of 
the  same  side.  Processes  from  cells  in  Clarke's  column  enter  the 
direct  cerebellar  tract  of  the  same  side  and  ascend  the  cord. 

Processes  from  cells  in  the  posterior  horn  traverse  the  gray 
matter  and  end  around  cells  in  other  parts  of  the  gray  matter, 
either  on  the  same  or  on  the  opposite  side,  above  or  below. 

Posterior  Roots. — Fibers  from  the  posterior  roots  enter  the 
cord  and  ascend  for  a  short  distance  along  Lissauer's  tract. 
They  then  enter  the  posterior  horns,  where  they  may  end  around 
cells  in  the  anterior  portion  on  each  side,  around  cells  near  the 
central  canal,  around  cells  in  the  posterior  portion,  around  cells 
in  Clarke's  column,  around  cells  in  the  anterior  horn  of  the  same 
or  the  opposite  side  etc.  Some  fibers  enter  the  column  of  Goll 
and  Burdach's  column  on  the  same  or  on  the  opposite  side, 
divide,  and  ascend  and  descend  (Figs.  17  and  19). 

In  some  regions  of  the  spinal  cord  collections  of  cells  occur 
that  seem  to  have  definite  functions.  These  cells  are  called 
centers.  The  most  important  of  these  centers  are  found  in  the 
sacral  region  of  the  cord.  Here  wt  have  the  rectal,  vesical,  and 
genital  centers.  Grouped  around  the  central  canal  throughout 
the  course  of  the  cord  are  the  vasomotor  centers.  At  about  the 
junction  of  the  first  dorsal  and  lower  cervical  are  the  ciliospinal 
centers  (Fig.  18). 

Important  Columns  and  Fiber-tracts  of  the  Spinal  Cord  (Figs. 
13,  14,  and  17). — The  spinal  cord  is  separated  by  means  of  ante- 
rior fissures,  anterior  roots,  posterior  roots,  and  the  postero- 
median sulcus  into  anterior,  lateral,  and  posterior  columns.  Be- 
tween the  anterior  roots  and  the  anterior  median  fissure  is  the 
anterior  column — one  to  each  half  of  the  cord.  Between  the  ante- 
rior roots  and  the  posterior  roots  is  the  lateral  column — one  to 
each  side  of  the  cord.  Between  the  posterior  roots  and  the  poste- 
romedian sulcus  is  the  posterior  column — one  to  each  half  of  the 
cord. 

Each  of  these  columns  is  further  subdivided  into  tracts.  A 
knowledge  of  the  origin,  course,  and  termination  of  these  tracts 
has  been  ascertained  as  the  result  of  embryologic  development, 
physiologic  experimentation,  and  clinicopathologic  observation. 


46  MANUAL   OF   NERVOUS   DISEASES 

The  anterior  column  contains  an  important  tract,  called  the 
direct  pyramidal  tract,  or  the  fasciculus  of  Tiirck,  which  is  con- 
tinuous with  the  uncrossed  fibers  of  the  pyramids  of  the  medulla. 
This  tract  is  most  marked  in  the  cervical  region,  gradually 
becoming  smaller  and  disappearing  in  the  lumbar  region. 

In  the  lateral  column,  just  in  front  of  the  posterior  horns,  and 
about  midway  between  the  lateral  surface  of  the  cord  and  the 
gray  commissure,  is  a  more  or  less  oval-shaped  tract,  known  as 
the  crossed  pyramidal  tract.  This  is  continuous  with  the  larger 
portion  of  the  pyramid,  descending  from  the  opposite  side  of  the 
medulla. 

Occupying  the  posterior  half  of  the  lateral  aspect  of  the  cord 
upon  its  outer  circumference  is  a  collection  of  fibers  termed  the 
direct  cerebellar  tract.  This  tract,  when  traced  upward,  is  found 
to  pass  into  the  inferior  cerebellar  peduncle  of  the  same  side. 

Anterior  to  this  pathway,  and  occupying  the  anterior  half  of 
the  lateral  circumference  of  the  cord,  as  far  forward  as  the  ante- 
rior roots,  is  the  anterolateral  ascending  cerebellar  or  Gowers'  tract. 
Between  the  posterior  horns  and  the  circumference  of  the  cord  is 
a  small  area  through  which  fibers  ascend  or  descend  for  a  short 
distance  before  entering  the  posterior  horns;  this  is  called 
Lissauer^s  marginal  tract. 

In  the  posterior  column,  immediately  adjacent  to  the  poste- 
rior horn,  is  a  collection  of  fibers  known  as  Burdach's  column,  or 
the  fasciculus  cuneatus.  Adjacent  to  the  column  of  Burdach, 
and  extending  to  the  posterior  median  septum,  is  another  group 
of  fibers,  known  as  the  column  of  Goll,  or  the  fasciculus  gracilis. 
Between  the  column  of  Goll  and  the  column  of  Burdach  is  a 
small  tract  termed  the  comma  tract  or  the  comma-shaped  bundle. 

In  the  lateral  columns,  extending  also  into  the  anterior  columns, 
are  numerous  fibers  that  originate  in  cells  situated  in  the  anterior 
part  of  the  posterior  horns  of  the  same  or  the  opposite  side. 
These  fibers  are  interspersed  with  numerous  other  fibers  situated 
in  this  region.  They  do  not  form  a  definitely  outlined  tract, 
but  are  grouped  and  described  under  the  name  of  the  antero- 
lateral ground-bundle . 

In  addition  to  these  tracts,  which  pursue  a  long  course  through 
the  spinal  cord  and  connect  the  cord  with  structures  in  the 


STRUCTURE    OF    THE    SPINAL    CORD  47 

cranial  cavity,  there  are  numerous  short  tracts  connecting  va- 
rious segments  of  the  cord  with  one  another.  There  are  also 
many  fibers  in  the  spinal  cord  that  pursue  an  oblique  course  and 
connect  dift'erent  levels  of  the  two  sides  of  the  cord  with  each 
other.     These  are  called  association  and  commissural  fibers. 

Origin  and  Termination  of  the  Important  Tracts  of  the  Cord 
(Fig.  19).— The  direct  pyramidal  tract,  or  fasciculus  of  Tiirck,  is 
made  up  of  10  per  cent,  of  uncrossed  pyramidal  fibers  from  the  me- 
dulla. These  fibers  have  their  point  of  origin  in  the  precentral  con- 
volutions of  the  frontal  lobe  of  the  brain.  The  direct  pyramidal 
tracts  occupy  the  median  portion  of  the  anterior  column.  At 
various  levels  in  the  cord  they  give  off  fibers  that  cross  the  ante- 
rior white  commissure  to  the  opposite  side  of  the  cord,  where 
they  enter  the  anterior  horn  and  terminate  around  the  large  cells, 
or  the  processes  of  these  cells,  in  the  anterior  horns. 

The  crossed  pyramidal  tract  is  made  up  of  90  per  cent,  of  fibers 
of  the  pyramids  of  the  medulla  which  have  crossed  in  the  lower 
part  of  the  medulla.  These  fibers  originate  on  the  precentral 
convolutions  of  the  frontal  lobe  of  the  brain.  They  descend  in 
the  lateral  columns  of  the  cord  on  the  side  opposite  to  which  they 
originate.  At  various  levels  in  the  cord  fibers  are  given  ofi"  that 
cross  through  the  lateral  columns  of  the  cord  and  the  gray  matter, 
and  end  around  cells  situated  in  the  anterior  horns. 

The  direct  cerebellar  tract  is  made  up  of  fibers  that  originate  in 
the  cells  in  the  column  of  Clarke  of  the  same  side.  These  fibers 
pass  through  the  posterior  horns  and  through  the  lateral  columns, 
and  enter  the  direct  cerebellar  tract,  which  is  situated  upon  the 
external  posterolateral  aspect  of  the  cord,  immediately  in  front 
of  the  posterior  roots.  This  tract  ascends  the  cord,  enters  the 
inferior  peduncle  of  the  cerebellum,  and  probably  ends  in  the 
central  lobe  of  the  cerebellum. 

Gowers^  tract,  or  the  anterolateral  ascending  cerebellar  tract, 
is  made  up  of  fibers  whose  cells  of  origin  are  situated  in  the 
posterior  horns.  These  fibers  cross  through  gray  and  white 
matter  into  this  tract,  which  is  situated  in  the  anterolateral  and 
external  aspect  of  the  cord,  immediately  behind  the  anterior 
roots.  The  tract  ascends  the  cord  and  enters  the  medulla,  where 
it  assumes  a  more  posterior  and  more  nearly  central  position. 


48  MANUAL   OF  NERVOUS  DISEASES 

Fibers  from  this  tract  are  believed  to  end  around  cells  in  the 
medulla,  pons,  and  cerebellum,  probably  on  the  opposite  side. 

The  anterolateral  ground-bundle,  situated  partly  in  the  lateral  x 
and  partly  in  the  anterior  column,  is  made  up  of  fibers  that  have\^' 
their  cells  of  origin  situated  in  the  anterior  part  of  the  poste- 
rior horns  of  both  sides,  the  greater  number  by  far  originating 
on  the  opposite  side,  crossing  through  the  gray  commissure 
in  an  ascending  direction.  These  fibers  ascend  in  the  antero- 
lateral portion  of  the  cord  and  enter  the  medulla,  where  they 
are  more  centrally  placed.  They  terminate  around  cells  in  the 
corpora  striata,  caudate  nuclei,  optic  thalami,  and  parietal  lobe 
of  the  brain.  In  this  tract  are  many  ascending  and  descending 
fibers  whose  cells  of  origin  and  point  of  termination  cannot  be 
accurately  determined. 

Lissauer^s  marginal  tract  is  made  up  of  fibers  whose  cells  of 
origin  are  in  the  ganglia  on  the  posterior  roots.  These  fibers 
enter  the  spinal  cord  as  posterior  roots,  and  ascend  for  a  very 
short  distance,  entering  either  the  gray  matter  to  terminate 
around  the  cells  or  pass  into  the  posterior  columns. 

The  column  of  Burdach,  or  the  fasciculus  cuneatus,  is  made  up 
of  fibers  having  their  cells  of  origin  in  the  ganglia  of  the  posterior 
roots.  After  entering  the  cord  they  ascend  for  a  short  distance 
along  Lissauer's  tract,  and  then  enter  the  column  of  Burdach. 
This  column  is  situated  immediately  adjacent  to  the  posterior 
horns  in  the  posterior  column. 

After  entering-  the  column  of  Burdach  some  of  the  fibers 
divide,  one  branch  ascending,  and  in  its  course  upward  being 
displaced  toward  the  central  line,  finally  ending  around  the  cells 
situated  in  the  lower  part  of  the  posterior  aspect  of  the  medulla, 
known  as  the  nucleus  of  Burdach,  or  the  nucleus  cuneatus.  The 
other  branch  descends,  and  in  its  course  gives  off  small  branches 
at  right  angles  that  enter  the  gray  matter  of  the  cord  to  terminate 
around  cells. 

The  column  of  Goll  (fasciculus  gracilis)  is  made  up  of  fibers 
that  have  their  cells  of  origin  in  the  ganglion  of  the  posterior 
roots.  These  fibers  enter  the  spinal  cord  as  the  posterior  roots, 
ascend  a  short  distance  along  Lissauer's  column,  and  then  enter 
the  column  of  Goll.     This  column  is  situated  on  each  side  of  the 


STRUCTURE    OF    THE    SPINAL    CORD 


49 


Direct  Pyramidal  tract. 


Temperature. 
'Pain. 
[Visceral  {equilibrium). 

Tactile. 

Muscular. 


Temperature. 

Pain. 

Visceral  iequilibriura) 

Tactile. 

Muscular. 


^ 

Temperature. 

Pain. 

Visceral  (equilibrium). 

Tactile. 

Muscular. 


-^ 


Anterolateral  ground-bundle 
{temperature,  pain,  and  tactile  sense). 


Fig.  19. — Longitudinal  section  of  spinal  cord,  showing  ascending  and  de- 
scending pathways. 


posteromedian  sulcus   in   the  posterior  column.     Some  of  the 
fibers  divide  as   they  enter  the  column  of  Goll,  one  branch 


50  MANUAL   OF   NERVOUS   DISEASES 

ascending  to  end  around  a  group  of  cells  situated  in  the  posterior 
aspect  of  the  medulla,  known  as  the  nucleus  of  GoU,  or  the 
nucleus  gracilis;  the  other  branch  descends  and  gives  off  in  its 
course  branches  at  right  angles  that  end  around  cells  in  the  gray 
matter.  The  fibers  that  are  given  off  at  right  angles  from  the 
descending  fibers  of  the  columns  of  Goll  and  Burdach  are  called 
collateral  fibers.  Schultze's  comma-shaped  tract  is  situated  be- 
tween the  columns  of  Goll  and  Burdach.  It  is  made  up  of 
descending  branches  of  fibers  from  the  columns  of  Goll  and 
Burdach. 

Pathways  of  Ascending  and  Descending  Degeneration. — 
Those  tracts  that  have  their  cells  of  origin  in  the  cord  and  trans- 
mit impulses  to  structures  above  are  called  ascending  pathways, 
and  degenerate  upward.  Those  tracts  that  have  their  cells  of 
origin  in  structures  above  the  cord  or  in  the  cord  and  transmit 
impulses  downward  are  called  descending  pathways,  and  degener- 
ate downward.  When  an  injury  or  a  disease  brings  about  a 
destructive  lesion  in  the  cord,  all  those  pathways  that  have  their 
cells  of  origin  below  the  lesion  will  show  degeneration  of  their 
fibers  above  the  lesion,  whereas  those  tracts  that  have  their  cells 
of  origin  above  the  lesion  will  show  degeneration  in  their  fibers 
below  the  affected  area  (Fig.  19). 

BLOOD-SUPPLY  OF  THE   SPINAL   CORD 

The  blood-supply  of  the  spinal  cord  is  derived  from  the  verte- 
bral arteries,  from  the  branches  of  the  dorsal  intercostals,  and 
from  the  lumbars.  These  branches  enter  the  spinal  canal  by  way 
of  the  intervertebral  foramina.  They  emerge  through  the  dura, 
and  some  of  the  branches  become  anterior  root  arteries  and  others 
become  posterior  root  arteries.  These  various  vessels  are  called 
the  lateral  spinal  arteries.  They  anastomose  on  the  anterior 
surface  of  the  cord,  and  form  the  anterior  arterial  plexus  and  the 
anterior  spinal  artery  (Fig.  20).  The  latter  extends  from  the 
medulla  to  the  lowest  part  of  the  cord.  The  posterior  root  arteries 
anastomose  with  each  other  but  not  with  those  of  the  opposite 
side,  and  form  the  posterolateral  arterial  plexus.  There  are  one 
anterior  arterial  plexus  and- two  posterolateral  arterial  plexuses. 


BLOOD-SUPPLY    OF    THE    SPINAL    CORD 


51 


^-^^ 


Fig.  20. — Spinal  cord,  showing  anterior  spinal  artery,  etc.  (Feigel). 


52 


MANUAL   OF   NERVOUS   DISEASES 


A  branch  arises  from  the  anterior  spinal  artery  which  is  called  the 
anterior  median  artery.  It  is  situated  deep  down  m  the  anterior 
fissure. 

From  the  anterior  median  artery  branches  are  given  off  that  sup- 
ply the  anterior  horns,  part  of  the  gray  commissure,  the  anterior 


Posterior  sulcal. 


Parasulcal. 


Posterior  lateral 
artery. 


Penetrating 
artery. 


Penetrating 
artery. 


Anterior  lateral 
artery. 


Anterior  fissural. 
Fig.  21. — Blood-supply  of  the  spinal  cord. 


portion  of  the  posterior  horns,  and  part  of  the  anterior  columns 
(Fig.  2i).  From  the  anterior  arterial  plexus  branches  are  given 
off  that  supply  the  white  matter  of  the  anterior  parts  of  the 
cord.  From  the  posterolateral  arterial  plexus  branches  are  given 
off  that  enter  the  cord  and  supply  the  white  matter  of  the  lat- 
eral tracts,  the  posterior  part  of  the  posterior  horns,  and  the 


PHYSIOLOGY    OF    THE    SPINAL    CORD  53 

posterior  tracts.  Each  penetrating  blood-vessel  is  an  end- 
artery,  i.  e.,  it  does  not  anastomose  with  any  other  artery.  The 
anterior  spinal  arteries  and  the  anterior  arterial  plexus  are  made 
up  of  large  blood-vessels  that  are  few  in  number.  The  postero- 
lateral plexuses  are  made  up  of  small  vessels  that  are  more 
numerous.  The  blood  is  collected  in  the  capillaries,  and  passes 
up  from  the  gray  matter  in  the  front  of  the  cord  and  in  front  of 
the  anterior  roots  into  a  number  of  minute  veins.  In  conse- 
quence of  this  the  blood-pressure  in  the  gray  matter  of  the  cord, 
as  well  as  in  the  anterior  part  of  the  cord,  is  high.  The  caliber  of 
the  arteries  is  large,  and  that  of  the  veins  is  small.  The  blood  is 
collected  from  the  capillaries  of  the  postero-arterial  plexus  in  a 
number  of  large  veins.  In  consequence  of  this  the  blood- 
pressure  in  the  lateral  tracts  and  in  the  posterior  parts  of  the 
cord  is  low. 

PHYSIOLOGY  OF  THE   SPINAL   CORD 

The  spinal  cord  exerts  a  more  or  less  direct  control  over  the 
various  parts  of  the  body.  This  control  is  proportional  to  the 
form  of  life,  being  most  complete  in  the  lowest  forms.  In  addi- 
tion to  this  function,  the  spinal  cord  is  the  pathway  through 
which  impulses  are  conducted  to  and  from  the  brain. 

Functions  of  the  Important  Cellular  Constituents  of  the  Spijial 
Cord. — ^The  group  of  large  cells  situated  in  the  anterior  horns, 
which  give  origin  to  the  anterior  roots,  preside  over  the  muscle 
tone,  muscle  nutrition,  and  muscle  contractility.  These  cells  are 
connected  with  groups  of  muscle-fibers.  When  they  are  irritated, 
fibrillary  muscular  contractions  take  place;  when  they  are 
stimulated,  muscular  contraction  occurs.  If  individual  groups 
of  cells  are  stimulated,  irregular  and  purposeless  muscular 
contractions  take  place.  If  physiologically  connected  groups 
are  stimulated,  purposive  muscular  contractions  result.  These 
cells  are  constantly  sending  out  stimuli  that  maintain  muscle 
tone  and  normal  muscle  nutrition.  Any  interference  with  their 
normal  activity  results  in  an  increase,  a  decrease,  or  a  perversion 
of  muscle  contractility,  muscle  tone,  and  muscle  nutrition. 

The  groups  of  small  cells  situated  around  the  central  canal 
that  send  their  processes  out  through  either  the  anterior  or  the 


54  MANUAL   OF   NERVOUS   DISEASES 

posterior  roots  in  some  way  combine  with  the  sympathetic 
nervous  system.  They  terminate  in  the  walls  of  the  small  blood- 
vessels. These  cells  preside  over  vascular  tonicity,  whereas 
others  seem  to  exert  their  influence  over  the  nutrition  of  the  skin 
and  its  appendages.  Still  others  terminate  around  the  sweat- 
glands,  the  sebaceous  glands,  and  in  other  glandular  structures, 
and  seem  to  influence  the  secretions. 

Numerous  small  cells  situated  in  the  posterior  horns  serve  as 
intermediate  stations  for  the  further  transmission  of  sensory  and 
coordinate  impulses.  Many  of  the  small  cells  scattered  through- 
out the  gray  matter  of  the  cord  act  as  commissural  cells,  giving 
origin  to  fibers  that  connect  the  two  sides  of  the  cord  with  each 
other.  Other  cells  give  origin  to  structures  known  as  association 
fibers,  which  connect  different  levels  of  the  cord  with  one  another, 
and  still  other  cells  serve  as  intermediate  stations  for  the  trans- 
mission and  wider  distribution  of  stimuli  that  result  in  reflex 
activity. 

In  certain  parts  of  the  cord  there  are  collections  of  cells  that 
preside  over  definite  functions  of  the  body;  these  are  called 
centers.  The  most  important  of  these  centers  are  situated  in 
the  lower  lumbar  and  sacral  region,  being  termed  respectively 
the  vesical,  the  rectal,  and  the  genital  centers.  Throughout  the 
entire  course  of  the  cord,  near  the  central  canal,  are  centers  known 
as  the  vasomotor  centers;  in  the  upper  dorsal  region  is  the  cilio- 
spinal  center,  etc. 

Function  of  the  Tracts  oj  the  Cord. — The  function  of  the  tracts 
of  the  cord  is  to  conduct  upward  and  downward  stimuli  that 
originate  in  the  centers  above  the  cord,  in  the  cord  itself,  or  in 
the  periphery.  The  tracts  are  divided  into  three  groups:  (i)  Pro- 
jection pathways,  which  transmit  stimuli  from  the  higher  centers 
to  the  cord  or  from  the  periphery  or  from  the  cord  to  the 
higher  centers.  (2)  Association  pathways,  those  which  connect 
different  levels  of  the  cord  with  one  another.  (3)  Commis- 
sural tracts,  which  connect  the  two  sides  of  the  cord  with  each 
other. 

The  Functions  of  the  Important  Projection  Pathways. — The 
important  projection  pathways  are  the  direct  pyramidal  tract, 
the  crossed  pyramidal  tract,  the  direct  cerebellar  tract,  the 


PHYSIOLOGY    OF    THE    SPINAL    CORD  55 

column  of  Goll  and  of  Burdach,  and  the  ascending  anterolateral 
ground-bundle. 

The  direct  and  crossed  pyramidal  tracts  transmit  impulses 
that  stimulate  the  anterior  horn  cells  to  activity  and  result  in 
voluntary  purposive  motor  activity.  These  pathways,  however, 
more  or  less  constantly  transmit  a  form  of  stimulation  that  exerts 
an  unconscious  restraining  or  inhibiting  effect  upon  the  anterior 
•horn  cells,  thereby  preventing  them  either  from  receiving  or  from 
sending  out  impulses  that  result  in  useless  reflex  activity.  This 
inhibiting  effect  can  be  increased  at  will.  As  the  result  of  a 
disturbance  of  normal  conductivity  of  these  pathways  there 
occurs  either  weakness  or  paralysis,  with  increased  reflex  action 
or  abnormal  motor  activity,  such  as  convulsion,  contracture, 
muscle  rigidity,  etc. 

Functions  of  the  Direct  Cerebellar  Tract. — This  pathway  trans- 
mits upward  that  form  of  sensation  by  which  equilibrium  is 
maintained. 

The  Functions  of  the  Column  of  Goll  and  of  Burdach. — These 
tracts  transmit  upward  muscle  sense  and  partial  tactile  sense. 

The  Function  of  the  Anterolateral  Ground-bundle. — IMany  of 
the  fibers  situated  in  this  tract  transmit  upward  the  sensation  of 
pain,  temperature  sense,  and  partial  tactile  sense.  Others  trans- 
mit impulses  upward  or  downward,  and  are  secondary  pathways 
for  motion  coordination,  sensation,  etc. 

Sensation  may  be  considered  under  at  least  three  subdivisions : 
the  epicritic  sense,  the  protopathic  sense,  and  deep  sensibility. 

The  epicritic  sense  is  the  finer  form  of  sensation  by  means  of 
which  differentiation  is  made  between  the  most  closely  related 
stimuli  and  the  most  delicate  forms  of  perception,  such  as  slight 
differences  of  temperature,  of  pain,  of  touch,  slight  changes  in 
the  location  of  stimuli,  etc. 

Protopathic  sensation  is  the  coarser  form  of  sensation.  By  it 
differentiation  can  be  made  only  between  the  more  widely 
separated  forms  of  stimulation,  such  as  marked  differences  in 
temperature,  heavy  touch,  sharp  pain,  etc. 

Deep  sensation  is  that  form  which  exists  in  the  joints,  muscles, 
etc.,  whereby  changes  in  position  of  the  various  parts  of  the  body 
to  each  other  are  recognized. 


56  •■  MANUAL   OF   NERVOUS   DISEASES 

Head  has  shown  that  epicritic  sensation  corresponds  to  per- 
ipheral nerve  distribution,  and  that  protopathic  sensation  corre- 
sponds to  posterior  root  distribution.  The  more  nearly  a  per- 
ipheral nerve  represents  the  supply  of  one  posterior  root,  the  more 
definite  will  be  the  outline  of  sensory  disturbance.  Conversely, 
the  greater  the  number  of  posterior  roots  that  enter  into  a  nerve, 
the  less  definite  will  be  the  border  of  sensory  disturbance,  and 
the  less  marked  will  be  the  protopathic  symptoms.  This 
observer  also  asserts  that  deep  sensation  is  transmitted  by  sen- 
sory filaments  in  the  motor  nerve. 

Sensation  may  be  further  divided  according  to  various  quali- 
ties; e.  g.,  tactile,  pain,  temperature,  and  muscle  sense. 

The  direct  cerebellar  tract,  the  columns  of  GoU  and  Burdach, 
and  the  anterolateral  ground-bundle  are  the  pathways  through 
which  the  various  forms  of  sensation  are  transmitted.  These 
pathways  do  not  conduct  the  various  types  of  sensation  indis- 
criminately, but  each  type  is  more  or  less  limited  to  a  special 
tract.  In  diseased  conditions  it  may  be  possible  for  the  various 
tracts  to  act  in  a  compensatory  manner. 

The  various  forms  of  sensation  are  received  by  the  peripheral 
nerves  at  their  termination  in  the  skin,  muscles,  joints,  glandular 
structures,  etc.  They  are  transmitted  toward  the  spinal  cord, 
and  the  impulses  then  go  through  the  ganglia  on  the  posterior 
roots,  and  enter  the  spinal  cord  by  means  of  the  posterior  roots. 
Upon  entering  the  cord  the  pathways  for  the  various  forms  of 
sensation  diverge. 

The  form  of  sensation  that  is  interpreted  as  muscle  sense,  or 
sense  of  position,  ascends  by  means  of  fibers  that  enter  the  col- 
umns of  GoU  and  Burdach  on  the  same  side.  The  stimuli  that 
are  responsible  for  maintenance  of  equilibrium,  after  entering 
the  spinal  cord  through  the  posterior  roots,  are  transmitted  to 
cells  in  the  column  of  Clarke  on  the  same  side.  From  these  cells 
the  stimuli  are  transmitted  by  the  fibers  of  the  direct  cerebellar 
tract  on  the  same  side,  to  ascend  and  stimulate  centers  situated 
above.  The  stimuli  that  are  interpreted  as  heat,  cold,  and  pain, 
upon  entering  the  spinal  cord  through  the  posterior  roots,  are 
transmitted  to  cells  situated  in  the  anterior  part  of  the  posterior 
horns.     From  these  ceUs  the  stimuli  are  transmitted  through 


PHYSIOLOGY    OF    THE    SPINAL    CORD  57 

fibers  that  cross  and  ascend  in  the  anterolateral  ground-bundle 
of  the  opposite  side.  The  stimuli  that  effect  tactile  sensation 
upon  entering  the  spinal  cord  pursue  two  courses:  one  is  similar 
to  the  muscle  sense,  that  is,  it  is  transmitted  upward  in  the 
columns  of  Goll  and  Burdach  of  the  same  side;  the  other  is  similar 
to  pain  and  temperature  sense,  that  is,  it  is  transmitted  upward 
in  the  anterolateral  ground-bundle  of  the  opposite  side. 

Functions  of  a  Segment  of  the  Spinal  Cord  and  Symptoms 
Arising  as  a  Result  of  a  Pathologic  Condition  of  a  Segment  of 
the  Cord. — A  segment  of  the  spinal  cord  is  that  part  of  the  cord 
that  gives  origin  to  one  set  of  spinal  nerves.  Each  segment 
of  the  spinal  cord  is  connected  with  a  definite  region  of  the 
body. 

The  function  of  a  segment  of  the  cord  is  to  preside  over  nutri- 
tion, the  tone,  the  vasomotor  state,  and  the  reflex  activity  of  a 
portion  of  the  bod}^,  and  to  allow  the  transmission  upward  and 
downward  of  stimuli  to  and  from  the  higher  centers. 

The  pathologic  conditions  affecting  a  segment  may  be  limited 
in  extent  to  the  gray  substance  or  to  the  white  matter.  The 
condition  may  be  diffuse,  involving  both  the  gray  and  white 
matter  on  both  sides,  or  it  may  be  limited  in  extent,  involving 
the  gray  and  white  substance  in  a  circumscribed  area  limited  to 
one  side,  or  it  may  partly  involve  both  sides.  On  the  other  hand, 
the  lesion  may  be  so  extensive  as  completely  to  disintegrate  one 
or  more  segments. 

The  S3Tnptoms  arising  from  these  pathologic  conditions  vary. 
Those  due  to  interference  with  the  gray  matter  manifest  them- 
selves in  a  loss  or  decrease  of  reflex  activity,  of  muscle  tone,  of 
muscle  nutrition,  and  of  muscle  power.  There  is  also  loss  or 
decrease  of  temperature,  of  pain,  and  of  partial  tactile  sense,  and 
there  are  trophic,  vasomotor,  and  secretory  disturbances.  The 
distribution  of  these  symptoms  corresponds  with  the  distribution 
of  the  spinal  ner^'es  connected  with  the  aft'ected  segment. 

The  s\Tnptoms  due  to  disturbance  of  the  tracts  of  the  segment 
are  weakness  or  paralysis,  wdth  increase  of  deep  reflexes  in  the 
part  of  the  body  situated  below  the  lesion,  loss  or  disturbance  of 
control  of  the  rectal  and  vesical  reflexes,  and  disturbance  or  loss 
of  tactile,  pain,  temperature,  and  muscle  sense  in  the  parts  of 


58  MANUAL   or   NERVOUS   DISEASES 

the  body  below  the  lesion.  If  the  lesion  involves  both  the  gray 
and  the  white  matter,  there  is  a  combination  of  the  aforesaid 
symptoms.  If  the  lesion  is  circumscribed,  the  symptoms  that 
result  will  depend  on  the  location  of  the  lesion;  for  example,  if 
the  lesion  is  limited  to  a  destruction  of  one-half  of  a  segment, 
the  Brown-Sequard  syndrome  occurs.  In  this  case  there  will 
be  atrophy,  loss  of  reflexes,  paralysis,  and  vasomotor  and  secre- 
tory disturbances  in  the  distribution  of  the  affected  segment  on 
the  same  side  of  the  body.  Below  the  lesion  on  the  same  side 
there  will  be  spastic  paralysis,  increase  of  deep  reflexes,  and  loss 
of  muscle  sense  and  partial  loss  of  tactile  sense.  On  the  opposite 
side  of  the  trunk  below  the  lesion  there  will  exist  loss  of  pain 
and  of  temperature  sense  and  partial  loss  of  tactile  sense. 

In  complete  destructive  lesions  of  the  spinal  cord  there  occur, 
below  the  lesion,  flaccid  paralysis,  loss  of  all  forms  of  sensation, 
abolition  of  all  reflex  activity,  loss  of  bowel  and  bladder  control 
and  of  muscle  tone,  marked  trophic  disturbances,  etc. 

No  satisfactory  explanation  has  ever  been  offered  for  the  com- 
plete loss  of  all  reflex  activity  and  the  abolition  of  muscle  tone, 
etc.,  after  complete  lesions  of  the  cord. 


ANATOMY  AND    PHYSIOLOGY   OF    THE    MEDULLA 
OBLONGATA,   PONS,   AND    CRURA 

The  Medulla  Oblongata. — The  medulla  is  continuous  with 
the  upper  end  of  the  spinal  cord.  On  its  anterior  surface  is 
the  anterior  median  fissure,  which  corresponds  with  that  of 
the  same  name  in  the  spinal  cord,  but  it  is  separated  from  it 
by  the  decussating  fibers  of  the  pyramids.  The  masses  of  white 
matter  lying  on  each  side  of  the  fissure,  known  as  the  pyra- 
mids, appear  at  first  to  be  continuous  with  the  anterior  columns 
of  the  spinal  cord,  but  in  reality  send  only  a  small  part  of  their 
fibers  to  the  anterior  column.  The  larger  portion  goes  to  the 
lateral  column  of  the  opposite  side,  to  form  the  crossed  pyram- 
idal tract. 

The  pyramids  are  bounded  laterally  by  the  anterolateral 
fissure.     From  this  fissure  emerge  the  root-bundles  of  the  hypo- 


ANATOMY    AND   PHYSIOLOGY    OF    MEDULLA    OBLONGATA       59 

glossal  nerve.  Lateralward  from  these  grooves,  in  the  upper 
part  of  the  medulla,  are  two  oblong,  egg-shaped  elevations  termed 
the  olives  (Fig.  22).  Posterior  to  the  olives  is  another  groove, 
which  corresponds  with  the  posterolateral  groove  of  the  spinal 
cord.    Posterior  again  to  these  grooves  are  two  round  elevations 


Semilunar  ganglion  of  trigeminal  nerve. 


A  hducens. 
Facial. 

N.  intermedius. 

Acoustic  nerve. 


Glossopharyngeal  nerve 

Vagu. 
Spinal  accessory  nerve. 


Hypoglossal  nerve 


— —Basilar  groove. 


Posterior  pontile 
recess. 


—  Decussation  of  pyramids. 


First  cervical  nerve. 


Ventral  fissure. 


Fig.  22.- 


-Anterior  view  of  the  pons  and  medulla,  showing  the  superficial 
origin  of  certain  cranial  nerves.     (Modified  from  Gray.) 


called  the  restiform  bodies,  which  are  apparently  continuous  with 
the  posterior  column  of  the  cord  and  disappear  into  the  cere- 
bellum. The  posterior  surface  of  the  medulla  is  continuous  with 
the  posterior  columns  of  the  cord.  The  upper  half  of  the  posterior 
surface  of  the  medulla  is  occupied  by  a  triangular  depression, 
the  apex  of  the  triangle  being  directed  downward.     This  de- 


6o  MANUAL  OF  NERVOUS  DISEASES 

pression  is  formed  by  the  separation  of  the  restiform  bodies,  and 
forms  the  lower  half  of  the  fourth  ventricle  (Fig.  23). 

The  medulla  is  covered  by  the  pia  and  arachnoid,  which  cover 
it  loosely,  forming  a  large  space  between  its  internal  surface  and 
the  pia  mater.  This  space  is  particularly  well  marked  on  the 
posterior  aspect  of  the  medulla. 

The  pia  sends  septa  into  the  medulla,  and  is  reflected  on  its 
posterior  aspect,  between  it  and  the  cerebellum,  where  it  is  cov- 
ered by  epithelial  cells,  forming  the  inferior  tela  choroidea.  At  the 
lower  edge  of  the  tela  choroidea,  just  above  the  calamus  scrip- 
torius,  is  a  small  opening  in  the  pia  through  which  the  intraven- 
tricular space  connects  with  the  subdural  space.  This  opening 
is  called  the  foramen  of  Magendie.  On  each  side  of  the  medulla, 
in  the  angle  between  it  and  the  cerebellum,  are  tw^o  other  small 
openings  in  the  pia,  which  also  allow  communication  between 
the  intraventricular  space  and  the  subdural  space.  These  open- 
ings are  called  {he  foramina  of  Retzius. 

The  medulla  presents  the  following  important  structures  for 
consideration:  On  the  anterior  aspect  wt  see,  on  either  side  of 
the  anterior  median  fissure,  a  round,  pyramidal  elevation  that 
extends  from  immediately  beneath  the  pons  to  the  lower  end  of 
the  medulla;  these  are  called  the  pyramids  of  the  medulla.  Ex- 
ternal to  the  pyramid,  in  the  anterolateral  groove,  appear  a 
number  of  nerve-fibers.  These  fibers  form  the  twelfth  or  hypo- 
glossal nerve,  and  the  point  of  their  appearance  is  called  the 
superficial  origin  of  this  nerve.  External  to  the  anterolateral 
groove,  immediately  beneath  the  pons,  is  an  oblong,  egg-shaped 
elevation  known  as  the  olive.  The  olivary  bodies  in  the  lower 
portion  are  frequently  crossed  by  arched  fibers  called  the  external 
arcuate  fibers.  On  each  side  of  the  central  line,  immediately 
below  the  pons,  and  almost  in  the  groove  between  the  pyramids 
and  the  olivary  body,  fibers  appear  that  form  the  abducens  or 
sixth  nerve.  The  point  of  appearance  of  these  fibers  is  called 
the  superficial  origin  of  the  sixth  nerve. 

In  the  posterolateral  groove  numbers  of  fibers  appear  that 
mark  the  superficial  origin  of  the  following  nerves:  Beginning 
above,  immediately  beneath  the  pons,  are  the  seventh  or  facial, 
the  eight  or  auditory,  the  ninth  or  glossopharyngeal,  the  tenth 


ANATOMY    AND    PHYSIOLOGY    OF    MEDULLA    OBLONGATA      6 1 

or  pneumogastric,  and  the  accessory  portion  of  the  eleventh  or 
spinal  accessory  nerve  (Fig.  22). 

On  the  posterolateral  aspect  of  the  medulla  are  two  rounded 
elevations  that  disappear  into  the  cerebellum.  They  are  called 
the  restiform  bodies,  or  inferior  peduncles  of  the  cerebellum. 


Brachia  pontis. 


Inferior  fovea 


Ala  cinerea 


f  Colliculi  anterior. 
\  Colliculi  posterior. 

Brachia  conjunc- 
tiva. 
Docus  ccetuleus. 


Superior  fovea. 


Stria:  medullares. 


Restiform  body. 
Tubercle  of  Rolando. 

Cuneate  tubercle. 
Clava. 

•Fascia  of  Rolando. 
Fascia  cuneatus. 
Fascia  gracilis. 


Fig.  23. — Posterior  view  of  pons  and  medulla  (Whitaker). 

The  dorsal  surface  is  divided  into  halves  by  the  posterior 
median  fissure,  continued  upward  from  the  cord.  On  the  dorsal 
surface  of  the  medulla,  in  each  half,  are  four  columns  or  tracts, 
separated  from  one  another  by  slight  grooves.  Close  to  the  mid- 
line are  the  fasciculus  gracilis  and  fasciculus  cuneatus;  external 
to  these  is  the  fasciculus  of  Rolando,  and  external  to  this  is  the 
direct  cerebellar  tract.  The  upper  half  of  the  dorsal  surface  of 
the  medulla  is  somewhat  wider  than  the  lower  half,  the  increase 


62  MANUAL   OF   NERVOUS   DISEASES 

in  width  being  progressive  from  below  upward.  The  lower  por- 
tion is  the  closed  portion  of  the  medulla;  the  upper  portion  forms 
an  open  triangle,  which  is  the  lower  half  of  the  fourth  ventricle. 
On  the  posterior  surface  of  the  medulla  are  slight  elevations  that 
contain  the  nucleus  cuneatus  and  the  nucleus  gracilis  (Fig.  23). 

Pons  Varohi. — ^The  pons  presents  the  appearance  of  an  inverted 
bridge  that  seems  to  span  the  medulla.  It  is  a  broad,  transverse, 
striated  band  that  disappears  laterally  into  the  cerebellum. 
The  lateral  portion  of  the  pons,  where  it  disappears  into  the 
cerebellum,  are  called  the  middle  peduncles  of  the  cerebellum. 
Upon  the  lateral  aspect  of  the  pons,  piercing  its  transverse  fibers, 
are  a  number  of  nerve-fibers  that  go  to  form  the  fifth  or  tri- 
geminal nerve.  The  point  at  which  they  appear  is  called  the 
superficial  origin  of  the  fifth. 

The  posterior  aspect  of  the  pons  is  occupied  by  the  upper 
half  of  the  fourth  ventricle  (Fig.  23). 

The  Fourth  Ventricle. — This  cavity  contains  a  small  amount 
of  fluid.  It  is  continuous  below  with  the  central  canal  of  the 
spinal  cord,  going  above  directly  into  the  aquaeductus  cerebri. 
The  anterior  wall  is  formed  by  the  posterior  aspect  of  the 
upper  half  of  the  medulla  and  the  pons  (Fig.  23). 

This  ventricle  is  a  lozenge-shaped  fossa,  the  lower  part,  be- 
tween the  restiform  bodies,  belonging  to  the  medulla  oblongata, 
the  medial  part  to  the  pons  Varolii,  and  the  upper  part  to  the 
isthmus.  The  lower  portion  is  approximately  triangular.  It 
appears  much  deepened  below,  and  is  marked  by  several  furrows 
that  converge  downward.  The  peculiar  convexity  of  its  sur- 
face in  the  lower  part  has  given  to  it  the  name  calamus  scrip- 
torius.  Along  its  lateral  and  inferior  margin  is  attached  the 
tela  choroidea.  The  upper  portion  is  bounded  on  each  side  by 
the  superior  cerebellar  peduncles,  and  is  covered  by  the  anterior 
medullary  velum.  It  gradually  narrows  into  the  aqueduct  of 
Sylvius.  The  fourth  ventricle  is  divided  into  symmetric  halves 
by  a  median  fissure.  Close  to  this  fissure  or  sulcus  on  each  side 
is  a  ridge,  and  external  to  this,  in  the  upper  part  of  the  floor  of  the 
fourth  ventricle,  is  a  dark-bluish  area  called  the  locus  ccBrideus. 
In  the  inferior  part  this  ridge  gives  off  a  triangular  area,  called 
the  trigonum  hypoglossi.    External  to  the  trigonum  hypoglossi 


ANATOMY    AND    PHYSIOLOGY    OF    MEDULLA    OBLONGATA      63 
is  a  narrow  area  called  the  ala  cincria.     Running  transversely 


Colliculi  }  ^^^i 

SticleusofZ  n 
Nucleus  of  \  n 
Locus  cceruUus 
Desc.  rvot  5  n. 


Spinal  root  - 
o/5n. 


/         Asc.  root  of 
frlosiopharyngeal. 


Nudei  of  Floor  of  ^tk  Ventricle, 


Spinal  root         12  «.      9n.  10«.  11«.       8 
of  5  n. 


4». 


11«.  lOn.  9«.  Olive. 

8k 


In     6  «•  ' 


.  Descending 
root  ofb  n. 


Fig  24  -Nuclei  of  the  floor  of  the  fourth  ventricle      (Whitaker,  "Anatomy 
of  the  Brain  and  spinal  Cord,"  after  Edmger.) 

across  the  fourth  ventricle,  about  its  median  part,  are  superficial 
white  fibers— the  medullary  stri«   or  striae  acoustics— which 


64  MANUAL   OF  NERVOUS   DISEASES 

arise  from  elevations  at  the  lateral  angle  of  the  fourth  ventricle, 
called  the  acoustic  tubercles.  These  fibers  disappear  in  the 
depths  of  the  median  fissure,  or  even  before  going  that  far. 

The  roof  of  the  fourth  ventricle — the  anterior  portion — is 
formed  by  the  cerebellum  and  the  superior  cerebellar  peduncles. 
The  latter  are  connected  by  a  lamina  of  white  matter,  the  anterior 
medullary  velum  or  valve  of  Vieussens,  which  is  continuous  with 
the  white  substance  of  the  cerebellum.  The  lower  part  is  cov- 
ered by  the  posterior  medullary  velum  and  the  tela  choroidea 
inferior,  which  is  a  double  fold  of  the  pia  mater.     From  its  inner 


Tela  cborl<.l.i,-;i  v,.,iirl.uli; 

'r:i.:iilj   >.iiliiinli  .,11.1111 


IVrlimtuluH  lloccuH 
b  litM-essus  IntcnilU 
i  ^  fQj?ttae  rhoniboidL'au 

•  Flocculus 


Fig.  25. — ^The  roof  of  the  fourth  ventricle  (Spalteholz). 

surface  are  given  off  a  number  of  projections  containing  blood- 
vessels; these  form  what  is  known  as  the  choroid  plexus  of  the 
fourth  ventricle  (Fig.  25). 

The  aquceductus  cerebri,  or  aqueduct  of  Sylvius,  is  a  narrow 
canal,  about  5  cm.  long,  which  passes  from  the  upper  end  of 
the  fourth  ventricle  through  the  crura  cerebri  to  the  third  ven- 
tricle.    In  cross-section  it  is  T  shaped. 

Cerebral  Peduncles. — ^These  are  two  large,  striped,  white  col- 
umns, situated  close  together.  They  emerge  from  beneath  the 
upper  margin  of  the  pons,  diverge  from  each  other,  and  pass 
upward  and  lateralward,  disappearing  beneath  the  optic  tracts 


ANATOMY   AND   PHYSIOLOGY   OF   MEDULLA   OBLONGATA      65 

into  the  cerebrum.  The  ventral  and  lateral  surfaces  are  free, 
and  are  called  the  basis  pedunculi.  That  portion  of  the  pe- 
duncles posterior  to  this  is  called  the  tegmentum.  Upon  the 
dorsal  aspect  of  the  cerebral  peduncles  are  the  corpora  quadri- 
gemina,  which  are  four  rounded,  arched  elevations — two  superior 
and  two  ii>ferior.  Below  the  corpora  quadrigemina,  and  extend- 
ing over  the  fourth  ventricle  as  part  of  its  roof,  are  the  brachia 
conjunctivae  cerebelli,  or  superior  cerebellar  peduncles  (Fig.  26). 


IVfm 
interjiosituvt. 

Poit. 
commiiunire. 

Pineal  ^f^'- 

bodv.  ^v 


Pedun-Je  •/ 
pineal  Ixxiy. 

\  if(X<ssa 

fnrn'x.  in't^.id'.' 


(Jfrpora 
qvadngemina,^ 


Agiitidiie/us  r^rebr, 
1  'altc  of  Vieussni.1 — !. 

\th  Ventricif. 


Optic  thalnmvx 
vnd  'ird  ventr. 

Foramen 

interf^ntru'iila  > 

^  Monro). 


Colli  iKT:(ie  fornicii 


Cerebellum  a'nd  ^ 
arbor  zitu- 


fnfundibTthnn . 


Fig.  26. — Mesial  section  of  brain,  shomng  the  fourth  ventricle,  aqueduct 
of  Sylvius;  cerebral  peduncles,  corpora  quadrigemina,  pineal  body,  etc. 
(Whitaker,  "x\natomy  of  the  Brain  and  Spinal  Cord.") 


Corpora  Quadri gemina. ^-Thtse  are  situated  upon  the  dorsal 
aspect  of  the  crura  cerebri,  immediately  in  front  of  and  directly 
in  contact  with  the  superior  cerebellar  peduncle^.  They  are  sub- 
divided by  a  median  flat  and  by  a  transverse  groove  into  four 
whitish,  hemispheric  elevations;  thus  we  have  an  inferior  and 
a  superior  corpus  quadrigeminus  on  each  side.  The  superior  or 
anterior  corpora  quadrigemina  are  larger  than  the  posterior  or 
inferior.  In  the  median  groove,  between  the  two  superior 
corpora  quadrigemina,  lies  the  pineal  gland.  Each  corpus 
quadrigeminus  is  continued  lateralward  and  upward  by  the 
corpora    quadrigeminal    arm.     The    superior    corpora    quadri- 


66 


MANUAL   OF   NERVOUS   DISEASES 


gemina  are  connected  by  means  of  these  arms  with  the  external 
geniculate  bodies,  and  the  inferior  corpora  quadrigemina  connect 
by  means  of  their  arms  with  the  internal  geniculate  body. 

STRUCTURE   OF  THE   MEDULLA,  PONS,   AND   CEREBRAL 

PEDUNCLES 

On  transverse  section  of  the  lower  part  of  the  medulla  it  will 
be  seen   that  its  gray  matter   presents  an  arrangement  very 


Fig.  27. — Sagittal  longitudinal  section  (medulla,  pons,  and  crura).     Dia- 
grammatic. 

similar  to  that  of  the  gray  matter  of  the  spinal  cord.    Higher 
up,  however,   the  arrangement  of  the  gray  matter  becomes 


STRUCTURE    OF    MEDULLA,  PONS,  CEREBRAL   PEDUNCLES    67 

much  changed.  The  anterior  horns  lose  their  characteristic 
shape,  owing  to  the  fact  that  the  fibers  of  the  pyramidal  tracts, 
in  their  course  from  the  medulla  to  the  lateral  columns  of  the 
cord,  cut  their  way  through  the  neck  of  the  anterior  horns; 
thus  detached,  the  head  of  the  horn  enlarges  and  is  pushed  to 
the  lateral  aspect  of  the  medulla  (Fig.  28). 

The  central  canal  of  the  spinal  cord  opens  out  into  the  floor 
of  the  fourth  ventricle,  and  the  base  of  the  anterior  horns  appear 
on  the  ventricular  floor  as  a  narrow  gray  tract.  The  greater 
part  of  the  anterior  horn  is  replaced  by  a  network  of  cells  and 
fibers.     This  network  constitutes  the  anterior  part  of  the  for- 


Funiculus  cuneatus 


Head  of  posterior  gray 
horn. 

Direct  cerebellar  tract.. 


Head  of  anterior  gray 


A  nterior  pyramid . 
horn. 


Funiculus  gracilis. 
Nucleus  gracilis. 


Spinal  root  of  fifth 
nene. 

Lateral  Pyramidal 
tract. 

Decussation  of 
pyramid. 


Fig.  28. — Transverse  section  through  medulla,  showing  motor  decussation. 


matio  reticularis.  On  reaching  the  medulla  the  gray  matter 
of  the  posterior  horn  also  takes  up  a  lateral  position.  The  gray 
matter  at  the  base  of  the  posterior  horn  increases  in  amount, 
and  forms  the  nucleus  of  the  column  of  Burdach  and  that  of  the 
column  of  GoU.  Around  the  cells  in  these  nuclei  the  fibers  of 
the  columns  of  GoU  and  Burdach  terminate,  and  from  these  cells 
arise  other  fibers  that  cross  the  middle  line,  forming  the  sensory 
decussation  (Fig.  29).  Then,  turning  upward,  they  go  to  form 
the  lemniscus,  or  fillet,  which  is  one  of  the  pathwa}-s  for  the 
conduction  of  sensation.  The  olivar}'  nucleus  is  contained  with- 
in the  olivary  body,  which  must  be  divided  in  order  to  bring  it 
into  \dew.     It  consists  of  flask-shaped,  multipolar  nerv^e-cells, 


68 


MANUAL   OF   NERVOUS   DISEASES 


arranged    concavely,    with   an   opening   on    its    inner   aspect. 
Through  this  opening,  called   the  hilum,   enters   the    olivary 


Nucleus  gracilis. 

Superficial  poste- 
rior arcuate  fibers. 


Sensory  decussa- 
tion. 

Tract  oj  the  fillet. 


Funiculus  gracilis. 

Funiculus  cunealus. 
Nucleus  cuneatus. 


Tubercle  of 
Rolando. 


Head  of  anterior 
gray  horn. 


^-.Anterior  pyramid. 


Fig.  29. — Transverse  section  through  medulla,  showing  sensory  decussation. 


peduncle,  which  connects  the  olivary  body  with  the  corpus 
dentatum   situated   in   the   opposite   side   of   the   cerebellum. 


Dorsal  nucleus 
of  va!;us 

Nucleus 
ambiguus 

Olivocerebellar  „ 
fiber 

Postei  lor 

longitudinal 

fasciculi. 


Anterior 
pyramid. 


Hypoglossal 
nucleus. 

Resliform  body. 
Fibers  of  ninth, 

tenth,  and 

eleventh 

nerves. 


Nucleus  _ 
lateralis. 


Inferior  olive. 
Twelfth  nerve. 


Fig.  30. — Transverse  section  of  medulla,  cutting  olivary  nucleus. 


These  fibers  cross  through  the  reticular  formation,  and  form  the 
principal  part  of  the  inferior  cerebellar  peduncle  (Fig.  30) . 


STRUCTURE    OF   MEDULLA,  PONS,  CEREBRAL   PEDUNCLES    69 

In  the  pons  the  fibers  of  the  motor  pathway  are  arranged  in 
bundles,  being  interlaced  with  the  transverse  fibers  (Fig.  31).  Be- 
hind the  pyramids  are  two  smaller  columns,  the  corticopontine 
and  the  caudate  cerebellar,  both  of  which  connect  the  cerebrum 
with  the  pontine  nuclei,  and  thence,  through  the  brachia  pontis, 
with  the  cerebellum.  Posterior  to  these  fibers,  near  the  dorsal 
aspect  of  the  pons,  are  the  following  distinct  set  of  longitudinal 
fibers:  First,  the  lemniscus  or  fillet,  near  the  midline,  in  the 
ventral  part  of  the  formatio  reticularis.     This  is  the  continuation 


Fou'th  vett-ide 
Substantia  /e, 
gtna 
Superior  cerebel 
lar  peJun  Ic 
Tegmental  area 
Lateral  fillet 
Mesial  fillet 


Ltngula  overlying  superior 
medullary  velum. 


Mesencephalic  root  of 


Gray  matter 
of  pontine 
nucleus 


Floor  of  fourth  ventricle. 
Paste  nor  longitudinal  fas- 
ciculus. 

'Nucleus  centralis 
superior. 


Transverse  pon- 
tine fibers. 

Pyramidal  tracts. 


Fig.  31. — Transverse  section  of  pons  at  upper  part. 


of  the  sensory  tracts  from  the  nuclei  of  GoU  and  Burdach  of  the 
medulla.  In  the  lateral  part  of  the  formatio  reticularis  of  the 
pons  are  found  the  fibers  of  the  anterolateral  tract,  which  have 
ascended  from  the  spinal  cord  through  the  lateral  columns  and 
the  formatio  reticularis  of  the  medulla.  This  set  of  fibers 
pursues  two  courses:  the  one  set,  called  the  spinothalamic,  form 
a  direct  route  for  the  transmission  of  the  sensations  of  touch, 
pain,  and  temperature;  the  other,  the  ventro-spinocerebellar, 
constitute  an  indirect  route  through  the  cerebellum  for  the 
transmission  of  these  same  types  of  sensation. 


70 


MANUAL   OF   NERVOUS   DISEASES 


Cross-section  of  the  cerebral  peduncles  will  show  that  each 
consists  of  two  portions — a  posterior,  called  the  tegmentum,  and 
an  anterior,  called  the  crusta.  These  two  parts  are  separated 
from  each  other  by  a  narrow  stratum  of  gray  matter  called  the  sub- 
stantia nigra  (Fig.  32).  The  tegmentum  is  a  larger  division  of  the 
crus,  and  is  composed  of  a  reticulum  of  longitudinal  and  trans- 
verse fibers  interspersed  with  gray  matter.  The  gray  matter 
consists  of  the  reticular  formation  continuous  with  that  of  the 
pons  and  the  medulla.  In  this,  in  addition  to  many  scattered 
nerve-cells  are  found  two  definite  collections  of  gray  matter — 
one  around  the  aqueduct  of  Sylvius  and  the  other  known  as  the 
red  nucleus.    The  red  nucleus  lies  beneath  the  anterior  pair  of  cor- 


JRuho-  spinal 

(lateral. 
Fillet  r 

xtnesial. 


Nticletis 
^d  nerve. 


Colliculi  anteriores. 

r-^^—Aqucedtictus  cerebri. 
teral\ 

'-  Fillet. 


Post,  longit. 
fascie. 

Ant.  longit. 
/usctc. 


Temporo-occipito 
pontine  tract. 


Nucleus''  / 

tuber.     Rub<U 
spituU  tract. 


3rd  nerve. 

Frimfo 
pontine  tract. 


Substantia 
nigra. 

'audate  cerebellair 
*^-^  tract. 

\     y'  "^Pyramidal  tracts. 
'   T 

Geniculate  fascic. 


Fig.  32, — Transverse  section  of  the  cerebral  peduncles  (Whitaker). 

pora  quadrigemina,  and  consists  of  multipolar  nerve-cells.  It  is 
the  primary  termination  of  the  superior  cerebellar  peduncles.  The 
gray  matter  around  the  aqueduct  of  Sylvius  gives  origin  to  the 
third  and  fourth  cranial  nerves.  The  white  matter  of  the  teg- 
mentum consists  of  longitudinal  and  transverse  fibers.  The 
chief  strands  are:  First,  the  superior  cerebellar  peduncles,  which 
connect  the  cerebellum  with  the  opposite  red  nucleus,  and 
through  this,  probably,  with  the  cerebral  cortex.  Second,  the 
fillet,  which  is  the  continuation  upward  of  the  main  sensory 
pathway  from  the  medulla  and  pons.  This,  when  continued 
upward,  is  found  to  terminate  around  the  cells  in  the  optic 
thalami,   cerebral  cortex,   and  inferior  and  superior  corpora 


STRUCTURE  OF  MEDULLA,  PONS,  CEREBRAL  PEDUNCLES  7 1 

quadrigemina.  Third,  the  rubrospinal  tract,  which  consists  of 
the  fibers  originating  in  the  cells  of  the  red  nucleus,  crossing  the 
opposite  side,  and  descending  through  the  medulla  to  the  lateral 
column  of  the  spinal  cord.  Its  fibers  terminate  around  the  cells 
in  the  anterior  horn. 

The  transverse  fibers  of  the  crura  are  the  fibers  of  the  third 
and  fourth  cranial  nerves  on  their  way  from  their  deep  to  their 
superficial  origin.  The  crusta,  or  base  of  the  peduncles,  lies  in 
front  of  substantia  nigra,  and  is  composed  of  the  following  tracts: 
The  internal  one-fifth  is  occupied  by  the  frontopontine  tract, 
which  is  made  up  of  fibers  that  connect  the  frontal  lobe  of  the 
cerebrum  with  the  pontine  nuclei.  The  middle  three-fifths  are 
taken  up  with  the  pyramidal  fibers,  in  the  following  order:  First 
appear  those  fibers  that  transmit  impulses  from  the  lower 
precentral  convolution;  that  is,  those  that  transmit  stimuli  to 
the  nuclei  of  the  cranial  nerves.  External  to  these  are  those 
fibers  that  originate  somewhat  higher  in  the  precentral  convolu- 
tion, and  transmit  impulses  that  effect  the  movements  of  the 
upper  extremities.  External  to  these  are  the  fibers  that  transmit 
impulses  that  bring  about  the  movements  of  the  trunk  and  the 
low^er  extremities.  The  external  one-fifth  is  occupied  by  the 
temporo-occipitopontine  tract. 

Functions  of  the  Medulla,  Pons,  and  Crura. — These  structures 
contain  fiber-tracts  that  conduct  stimuli  upward  and  downward. 
Those  situated  anteriorly  are  the  motor  pathways  that  transmit 
impulses  from  the  brain,  which  bring  about  voluntary  move- 
ments and  which  inhibit  activities  not  desired.  Posterior  to 
these  pathways  are  the  tracts  through  which  ascend  the  stimuli 
that,  on  being  impressed  on  consciousness,  we  perceive  as  the 
various  types  of  sensation.  Interspersed  between  these  two 
pathways,  at  various  levels,  are  the  cranial  nerves.  The  rela- 
tive spatial  relationship  of  the  nuclei  and  the  fibers  of  these 
nerves  to  the  ascending  and  descending  pathways  can  best  be 
understood  from  a  study  of  longitudinal  and  cross-sections  of 
these  structures  (Figs.  24,  27,  and  33). 

Corpora  Quadrigemina. — The  superior  pair  of  corpora  quadri- 
gemina consists  of  several  layers  of  gray  and  white  matter.  The 
posterior  pair  is  composed  of  a  central  gray  core  and  a  white 


72 


MANUAL   OF  NERVOUS   DISEASES 


Corh^ 


. .  Bired  Cerebellar  Tract 
^Crossed.  P^ramida-J  Tract 
Direct  PyramidaJ  Tract 
./!nt/at  Ground  Sur}d/e 

I}jlumn  o'fGoll 

Colomn  of  Burdach 


Post.  Root  Fiberf 


'Ant  Root  Tibers 


Fig-  33-— Longitudinal  diagrammatic  section  of  the  crura,  pons,  medulla, 
and  upper  part  ot  spinal  cord,  showing  the  principal  ascending  and  descend- 
mg  tracts,  the  nuclei  and  fibers  of  the  cranial  nerves  from  the  third  to  the 
twelfth,  and  their  relation  to  each  other. 


THE    CEREBELLUM 


73 


cortex.  The  superior  corpora  quadrigemina  and  the  external 
corpora  geniculata  are  concerned  with  vision;  the  inferior 
corpora  and  the  internal  corpora  geniculata  are  concerned  with 
hearing.  These  bodies  vary  in  size  in  different  animals,  and 
bear  a  direct  relation  to  the  function  of  sight  and  to  the  acuteness 
of  hearing. 

THE   CEREBELLUM 

The  cerebellum,  or  small  brain,  is  situated  behind  the  pons 
and  medulla,  and  is  contained  within  the  occipital  fossa.  It  lies 
beneath  the  posterior  lobes  of  the  cerebrum,  from  which  it  is 


Brachia 
pqntis. 


Pons. 


'  >         Pedunculi 

\.^      cerebri. 


Corpiis 
dentatum 


Medulla. 


Fig.  34. — Median  section  of  the  cerebellum.     (Whitaker,  "Anatomy  of  the 
Brain  and  Spinal  Cord.") 


separated  by  the  tentorium  cerehelli.  It  measures  about  three 
to  four  inches  transversely,  and  from  two  to  two  and  one-half 
inches  anteroposteriorly.  It  is  about  two  inches  thick  in  the 
center,  becoming  gradually  thinner  as  the  outer  circumference 
is  approached.  The  surface  of  the  cerebellum  is  traversed  by 
numerous  narrow^  furrows  that  vary  in  depth  (Fig.  34) . 

In  structure  the  cerebellum  consists  of  gray  and  of  white 
matter,  the  former  being  darker  than  that  of  the  cerebrum,  and 
occupying   the   surface;   the  latter   occupies   the   interior.     It 


74 


MANUAL   OF   NERVOUS   DISEASES 


consists  of  a  median  division,  called  the  vermiform  process;  two 
lateral  divisions,  the  cerebellar  hemispheres;  and  three  peduncles 
— the  superior,  middle,  and  inferior — by  means  of  which  the 
organ  is  brought  into  communication  with  the  cerebrum,  the 
pons,  and  the  medulla. 

The  anterior  margin  of  its  surface  presents  in  the  middle  a 
flat  notch,  the  anterior  cerebellar  incision,  which  lodges  the  pons 
and  the  medulla.  The  cerebellar  hemisphere  presents  three 
surfaces — an  anterior,  a  superior,  and  an  inferior.  The  superior 
and  inferior  are  separated  from  each  other  by  the  great  horizontal 


Ala  lohi  renlralis  - 
Lobus  centralis.  . 


f  Ciilmen.- 


Monliculus  J 
cerebelli 


I 

[    Clivus. 


Commissura  simplex- 


Horizontal  fissure 


~  "Corpora  quadrigemina. 


Incisura  cerebelli  ante- 
rior. 

-Anterior       \ 

crescentic  \  Lobus  an- 
I  terior.  su- 
f  perior.   or 
Posterior       j  nuadrate. 
crescentic  J 


Lobus  posterior  supetior 
"'     or  semilunar  lobe. 


Incisura  cerebelli  posterior. 
Fig.  35- — Upper  surface,  cerebellum  (Whitaker). 


fissure.  The  cerebellar  hemisphere  consists  of  a  central  white 
core,  a  little  central  gray  matter,  and,  on  the  surface,  numerous 
crescentic  gray  laminae  with  their  convexity  directed  backward. 

The  upper  surface  of  each  cerebellar  hemisphere  is  concave, 
and  they  are  separated  from  each  other  in  the  midline  by  a 
longitudinal  elevation  which  is  the  upper  surface  of  the  vermis 
cerebelli  (Fig.  35). 

The  under  surface  of  each  hemisphere  is  convex,  and  the  two 
hemispheres  are  divided  from  each  other  by  a  median  furrow  in 
which  is  seen  the  inferior  surface  of  the  vermis  cerebelli  (Fig.  36). 


THE  CEREBELLUM 


75 


Posteriorly,  the  hemispheres  are  separated  by  the  posterior 
cerebellar  groove,  which  receives  the  free  anterior,  margin  of  the 
falx  cerebelli. 

The  anterior  surface  of  the  cerebellum  presents  in  the  midline 
a  notch,  the  anterior  cerebellar  groove,  which  lodges  the  pons 
Varolii  and  the  medulla.  When  these  structures  are  removed, 
there  are  revealed  in  the  midline  the  following  structures:  The 
anterior  end  of  the  vermis  cerebelli,  the  valve  of  Vieussens,  and 
the  cavity  of  the  fourth  ventricle;  on  each  side  is  seen  a  cerebellar 
hemisphere  with  its  three  peduncles;  externally,  in  the  midline, 
is  the  longitudinal  sulcus,  in  which  is  lodged  the  flocculus. 


Brachia  con- 
junctiva.   ' 


Lobus  gracilis 


Posterior  infe- 
rior or  inferior , " 
semilunar  lobe. 


Fifth  nerve. 

—  Sixth  nerve. 

Seventh  nerve. 
"'Eighth  nerve. 
~- Flocculus. 

Inferior  medul- 
lary velum. 

Furrowed  band. 


"-Uvula. 


Pyramid. 


Incisura  cerebelli  posterior.  Tuber  vermis. 

Fig.  36. — Under  surface  of  cerebellum  (WTiitaker). 


The  surfaces  of  the  cerebellar  hemispheres  present  a  laminated 
appearance.  The  furrows,  extending  continuously  on  the  upper 
surface  over  the  vermis,  run  approximately  parallel  to  the  pos- 
terior margin.  The  superior  and  inferior  surfaces  of  the  cere- 
bellum are  divided  into  lobes,  some  of  which  are  very  poorly 
defined. 

The  Peduncles  of  the  Cerebellum. — These  are  bilateral  bands 
of  white  matter,  three  to  each  hemisphere — the  superior,  the 
middle,  and  the  inferior.  They  connect  the  cerebellum  with 
the  cerebrum,  with  the  pons,  and  with  the  medulla  (Fig.  37). 


76 


MANUAL  OF  NERVOUS  DISEASES 


The  superior  peduncles,  or  brachia  conjunctiva,  are  two  white 
bands  situated  beneath  the  anterior  part  of  the  cerebellum. 
They  connect  the  white  substance  of  the  hemispheres  with  the 
cerebral  peduncles.  They  run  upward  and  forward,  forming 
part  of  the  lateral  walls  of  the  upper  part  of  the  fourth  ventricle, 
the  interval  between  them  being  bridged  over  by  a  valve  of 
Vieussens  or  the  superior  medullary  velum.     As  they  ascend 


Fig.  37. — The  peduncles  of  the  cerebellum.  On  the  left  the  three  peduncles 
have  been  cut  at  their  entrance  into  the  cerebelhim;  on  the  right  side  they 
are  shown  penetrating  the  cerebellar  hemisphere  (Poirier  and  Charpy). 


the  peduncles  meet  in  the  midline  and  form  part  of  the  roof  of 
the  fourth  ventricle.  The  fibers  that  form  the  superior  pe- 
duncles originate  chiefly  in  the  corpus  dentatum,  which  is  a  mass 
of  gray  matter  in  the  interior  of  the  cerebellum.  Some  of  the 
fibers  of  these  peduncles  also  originate  in  the  cells  of  the  cere- 
bellar cortex.  The  majority  of  the  fibers  of  the  peduncles 
decussate  wdth  those  of  the  opposite  peduncle,  and  then  pass 
upward  as  a  distinct  bundle  with  the  uncrossed  fibers.     They 


»THE    CEREBELLUM  77 

then  divide  into  the  ascending  and  descending  branches.  The 
ascending  branches  terminate  around  the  cells  in  the  cere- 
brum, cells  in  the  red  nucleus,  in  the  optic  thalamus,  etc. 
The  descending  branches  pass  downward  in  the  reticular  forma- 
tion of  the  pons  and  medulla,  ending  around  the  nuclei  of  the 
motor  cranial  nerves. 

The  middle  peduncles,  or  hrachia  pontis,  are  a  continuation  of 
the  lateral  part  of  the  pons  into  the  cerebellum,  and  are  made  up 
of  the  fibers  that  lie  above  the  superficial  origin  of  the  fifth 
cranial  nerve.  The  fibers  of  the  middle  peduncles  become  in- 
corporated with  the  pons,  forming  deep  and  superficial  trans- 
verse fibers.  Some  of  the  fibers  of  these  peduncles  are  commis- 
sural, connecting  the  two  sides  of  the  cerebellum;  others  termi- 
nate around  the  pontine  nuclei  of  the  opposite  side,  and  a  few 
terminate  in  the  same  side  (Fig.  38). 

The  inferior  cerebellar  peduncles,  or  restiform  bodies,  are  two 
round  elevations  that  ascend  from  the  medulla  to  enter  the 
white  matter  of  the  cerebellar  hemispheres.  They  form  the  lat- 
eral boundaries  of  the  lower  part  of  the  fourth  ventricle.  The 
fibers  of  the  inferior  peduncles  originate  in  the  spinal  cord,  in 
the  medulla,  in  the  olivary  bodies,  and  in  the  cerebellum. 
Spinal  fibers;  these  are  the  direct  cerebellar  tract  ascending  from 
the  same  side  of  the  cord,  and  the  arciform  fibers  which  have 
originated  in  the  nuclei  of  the  posterior  column  of  the  same 
and  opposite  side;  the  fibers  from  the  medulla  originate  in  the 
sensory  portion  of  the  nuclei  of  the  tenth,  ninth,  fifth,  and  the 
vestibular  portion  of  the  eighth  nerves;  the  olivary  fibers  orig- 
inate in  the  olives  of  the  opposite  side;  the  cerebellar  fibers  are 
descending  fibers  from  the  cerebellum  to  the  nuclei  of  the  cranial 
nerves  and  to  cells  in  the  spinal  cord.  Most  of  the  fibers  of  the 
inferior  cerebellar  peduncles  end  around  or  originate  m  the  cells 
of  the  vermis  of  the  opposite  side. 

The  valve  of  Vieussens,  the  superior  medidlary  velum,  is  a  deli- 
cate sheath  of  nerve  substance,  triangular  in  shape,  the  apex 
being  directed  forward.  It  forms  part  of  the  roof  of  the  upper 
division  of  the  fourth  ventricle,  and  is  placed  anteriorly  across 
the  interval  left  between  the  two  superior  cerebellar  peduncles. 
The  gray  and  white  matter  of  this  structure  is  continuous  with 
the  gray  and  white  matter  of  the  cerebellar  hemispheres. 


78 


MANUAL   or   NERVOUS   DISEASES 


Fig.  38. — Diagram  showing  course  of  fibers  which  make  up  the  cerebellar 
peduncle:  S,  Superior  cerebellar  peduncles,  made  up  as  follows:  fibers  origi- 
nating in  the  cells  of  the  red  nucleus  in  the  cerebellar  peduncles  of  the  same 
and  opposite  sides;  fibers  originating  in  or  terminating  around  cells  in 
the  corpora  quadrigemina.  M,  Middle  cerebellar  peduncle,  made  up  as  fol- 
lows: fibers  which  originate  in  the  pontile  nuclei  of  the  same  and  opposite 
side,  commissural  fibers  which  connect  the  two  cerebellar  hemispheres  with 
each  other  and  with  the  middle  lobe  of  the  cerebellum.  /,  Inferior  cere- 
bellar peduncle,  made  up  as  follows:  direct  cerebellar  tract  which  originates 
in  the  cells  of  Clarke's  column ;  external  and  internal  arciform  fibers  which 
originate  in  the  cells  in  the  nuclei  of  Goll  and  Burdach  on  the  same  and  oppo- 
site side;  fibers  which  originate  in  the  dentate  nucleus  of  the  opposite  in- 
ferior olive;  fibers  from  the  nuclei  of  the  cranial  nerves,  especially  the 
vestibular  portion  of  the  eighth  nerve. 


THE    CEREBELLUM  79 

Structure  of  the  Cerebellum. — The  cerebellum  is  made  up  of 
gray  and  white  matter.  The  gray  matter  consists  of  two  parts: 
that  on  the  surface  is  called  the  cortex  cerebelli,  and  that  in  its 
interior  is  known  as  the  nuclei  cerebelli.  The  cortex  cerebelli 
forms  a  thin  lamina  that  is  folded  upon  itself  in  a  series  of  leaves 
or  blades;  these,  upon  section,  present,  with  the  white  matter, 
a  tree-like  appearance  called  the  arbor  vitae. 

The  nuclei  cerebelli  are  situated  in  the  cerebellar  hemi- 
sphere— corpora  dentata — one  in  each  hemisphere.  They  are 
similar  in  structure  to  the  corpora  dentata  of  the  olivary  body, 
and  are  closely  connected  to  it.  They  consist  of  brown  nerve 
substance  inclosing  white  matter,  the  whole  forming  a  pouch- 
like structure  that  is  open  at  its  upper  and  inner  sides.  Through 
these  openings  nerve-fibers  enter  the  corpus  dentatum.  These 
fibers  can  be  traced  from  the  superior  peduncles,  from  the 
valve  of  Vieussens,  and  from  the  inferior  cerebellar  peduncles. 
There  are  three  other  nuclei  within  the  cerebellum.  These  are 
situated  near  the  midline,  internal  to  the  corpus  dentatum,  and 
are  named  the  nucleus  globosus,  the  nucleus  emboliformis,  and 
the  nucleus  fastigii. 

The  white  matter  of  the  cerebellum  is  made  up  of  three  sets 
of  fibers — projection,  commissural,  and  association.  The  pro- 
jection fibers  constitute  the  peduncles  of  the  cerebellum;  the 
commissural  fibers  extend  from  one  hemisphere  to  the  other, 
while  the  association  fibers  connect  the  \arious  convolutions 
with  one  another. 

Microscopic  Structure  of  the  Cerebellum.— The  gray  cortex 
of  the  cerebellum  consists  of  three  layers— the  outer  or  molecular 
layer;  a  middle  layer  of  Purkinje's  cells,  and  an  inner  or  granular 
layer.  The  outer  layer  forms  a  clear  gray  stratum  on  the  surface 
of  the  cerebellum.  It  is  composed  of  neuroglia  and  of  large  and 
small  molecular  cells.  The  latter  are  multipolar  cells,  their  axis- 
cylinder  processes  running  transversely  into  the  granular  layer, 
and  giving  off  at  right  angles  branches  whose  terminal  twigs 
envelop  the  bodies  of  the  cells  of  Purkinje.  Owing  to  this 
arrangement,  many  of  the  cells  of  this  layer  are  called  "  basket- 
cells"  (Fig.  39). 

The  middle  layer  is  formed  of  the  cells  of  Purkinje.    These 


8o 


MANUAL   OF   NERVOUS   DISEASES 


cells  are  characteristic  of  the  gray  matter  of  the  cerebellum, 
and,  owing  to  their  shape,  have  also  been  called  "antler  cells." 
The  large,  flask-shaped  cell-body  and  the  dendritic  process  are 
directed  toward  the  surface  of  the  cerebellum.  They  divide 
and  subdivide  like  the  branches  of  a  tree  or  the  horns  of  a  deer, 
They  are  closely  surrounded  by  many  fine  fibrilla.     From  the 

Cerebellum —  Structure. 


Small 

molecular. 

cell. 

Large  granular 
cell. 


Tendril, 
fibres 


Protoplasmic, 
process. 

Large 

malecular 

'cell. 


Middle  layer 

or  layer  of 

Purkinje's  cells 


Small 

granular 

ceU. 


Axone  of 
Purkinje's  cell. 


Moss  fibres. 


Axone  of 
la/rge  molecular  cell. 


Neuroglit 
cells. 


Molecular 
layer 


Granular 
layer 


Fig.  39. — Microscopic  structure  of  cerebellum.     Diagrammmatic.     (Whit- 
aker,  "Anatomy  of  the  Brain  and  Spinal  Cord.") 


larger  end  of  the  cell  a  single,  slender  axis-cylinder  process  is 
given  off.  This  sends  off  a  lateral  process  and  then  enters  the 
white  matter. 

The  inner  layer  consists  of  large  and  small  granular  cells, 
neuroglia,  a  fine  network  of  fine  interlacing  fibrilla  of  axis- 
cylinder  processes  passing  toward  the  molecular  layer.  Fibers, 
known  as  "moss  fibers,"  are  also  present;  they  ascend  from  the 


THE   CEREBRUM  8 1 

gray  matter  of  the  cord,  and  end  as  short,  thick  branches  or  as 
little  mossy  tufts  in  the  cortex.  Fibers  that  end  in  a  plexus  in 
the  molecular  layer,  and  are  called  "climbing"  or  "tendril  fibers," 
are  also  seen. 

Functions  of  the  Cerebellum. — The  hemispheres  of  the  cere- 
bellum may  be  even  irritated  or  removed  without  giving  rise 
to  any  symptoms.  These  structures  are  probably  connected 
with  the  sympathetic  system  and  with  the  frontal  lobes,  and 
exert  an  influence  upon  the  emotions. 

The  middle  lobe,  or  vermis,  seems  to  be  that  portion  concerned 
mostly  with  the  important  activities  of  the  cerebellum.  It  has 
a  marked  influence  on  the  muscle  movements;  for  example, 
disturbance  of  the  middle  lobe  may  cause  forced  movements, 
tremors,  and  cataleptic  attitudes.  The  cerebellum  is  the  con- 
trolling center  wherein  are  combined  the  many  stimuli  that 
result  in  coordination.  Diseases  of  the  cerebellum  may  bring 
about  incoordination;  abnormalities  of  movements;  ataxia; 
vertigo;  speech  disturbance;  nystagmus;  adiadokokinesis;  dis- 
turbance of  equilibrium,  etc. 


THE    CEREBRUM 

The  cerebrum  is  by  far  the  largest  division  of  the  brain.  It 
presents  a  surface  convex  from  before  backward  and  from  side 
to  side,  which  corresponds  to  the  inner  surface  of  the  skull.  Its 
inferior  surface  occupies  the  anterior  and  middle  fossae  of  the 
skull,  and  posteriorly  rests  upon  the  upper  surface  of  the  ten- 
torium cerebelli,  which  separates  it  from  the  cerebellum. 

It  is  an  egg-shaped  mass,  larger  behind  than  in  front,  and 
composed  of  two  symmetric  halves  that  are  partly  united  in  the 
midline.  Each  half  presents  a  flat  median  surface,  a  convex 
lateral  surface,  and  an  irregular  inferior  surface.  These  halves, 
or,  as  they  are  called,  cerebral  hemispheres,  are  united  by  a  thick 
band  of  white  matter  known  as  the  corpus  callosum.  They  are 
separated  from  each  other  by  the  great  longitudinal  fissure,  in 
which  is  placed  the  falx  cerebri.  Each  hemisphere  is  composed 
of  a  white  stalk  or  peduncle,  surrounded  by  a  convoluted  gray 

6 


82 


MANUAL   OF   NERVOUS   DISEASES 


mass.  This  is  traversed  by  indentations  called  fissures,  or 
sulci,  which  divide  the  mass  into  larger  and  smaller  folds,  which 
are  termed  convolutions,  or  gyri.  Internally,  the  hemispheres 
consist  of  masses  of  gray  matter, — the  subcortical  ganglia, — of 
white  matter,  made  up  of  nerve-fibers,  and  of  a  cavity, — the 
cerebral  ventricle. 


[•'rouliil  pole 


.1/.'/,.,-  iircci  fur 
a.  htud  •iiiff  iia  J< 

I      for  trunk. 

•I .  for  itfwer  Lbn.b. 


FUs. 
parieto-i^xipii 


Orripituf  pole. 


fjobuJi 


Fig.  40. — Cerebrum  as  seen  from  abo\'c  (Whitaker). 

Fissures. — The  surface  of  a  cerebral  hemisphere  is  marked 
by  numerous  elevations  and  depressions,  some  of  which  are 
practically  constant  as  to  location.  The  largest  of  these  depres- 
sions divide  the  surface  of  the  cerebrum  into  lobes,  and  the  smaller 
ones  subdivide  these  lobes  into  convolutions  or  gyri.  The  most 
constant  and  most  evident  fissures  are  the  fissure  of  Sylvius, 
the  fissure  of  Rolando,  and  the  parieto-occipital  fissure. 


THE    CEREBRUM 


83 


The  fissure  of  Sylvius  is  a  deep  indentation  which  begins  near 
the  midline,  on  the  under  surface  of  the  hemisphere,  at  a  point 
called  the  anterior  perforated  space.  It  runs  transversely  up- 
ward and  outward  on  the  base  of  the  hemisphere  to  its  lateral 
aspect,  where  it  divides  into  two  limbs — an  anterior  short  vertical 
ascending  limb,  and  a  posterior  one,  which  runs  horizontally 
backward  on  the  surface  of  the  hemisphere,  and  is  therefore 
called  the  horizontal  limb. 

The  fissure  of  Rolando  is  one  of  the  first  fissures  to  appear  in 
the  development  of  the  brain.     It  commences  above,  at  the 


Cent/ 


^«/ 


°'-a.l  Lobe. 

Fig.  41. — Lateral  view  of  brain,  showing  lobes,  fissures,  and  convolutions. 


median  longitudinal  fissure,  in  many  cases  on  the  median  surface 
of  the  hemisphere,  posterior  to  the  anterior  half  of  the  hemi- 
sphere. It  descends  obliquely  forw^ard  across  the  outer  surface 
of  the  cerebrum,  and  ends  below,  near  the  anterior  part  of  the 
horizontal  limb  of  the  fissure  of  Sylvius,  which  it  rarely  enters. 
The  parieto-occipital  fissure  appears  on  both  the  outer  and  the 
median  aspect  of  the  hemisphere.  Externally  it  is  a  short  cleft 
on  the  outer  aspect  of  the  hemisphere,  at  about  the  junction  of 
the  anterior  five-sixths  and  the  posterior  sixth  of  the  total  dis- 
tance from  the  posterior  to  the  anterior  pole.     The  internal 


84 


MANUAL   OF  NERVOUS   DISEASES 


portion  of  this  fissure  is  well  marked  and  descends  vertically  in 
the  posterior  portion  of  the  median  aspect  of  the  hemisphere 

(Fig.  43)- 

These  fissures  divide  each  cerebral  hemisphere  into  four 
principal  lobes,  which  take  their  names  from  the  portion  of  the 
skull  beneath  which  they  lie.  These  are  the  frontal,  the  parietal, 
the  temporal,  and  the  occipital  lobes.  The  fifth  lobe,  which  is 
called  the  central  lobe,  or  the  island  of  Reil  (Fig.  42),  is  hidden 
within  the  fissure  of  Sylvius.  Two  other  lobes  are  sometimes 
described:  the  olfactory  and  the  limbic  lobe. 


.•Siilc«i«  circnlariB 
';*i./  illtillj        U 


Fig.  42. — Central  lobe,  or  island  of  Reil  (Spalteholz). 

Lobes  of  the  Brain. — The  frontal  lobe  is  pyramidal  in  shape, 
occupying  the  anterior  portion  of  the  cerebral  hemisphere.  It 
is  limited  posteriorly  by  the  fissure  of  Rolando,  and  inferiorly  by 
the  fissure  of  Sylvius.  It  is  separated  from  the  frontal  lobe  of 
the  opposite  side  by  the  great  longitudinal  fissure.  It  has  an 
outer,  inner,  and  an  inferior  surface.  The  outer  surface  is 
marked  by  three  important  sulci — the  precentral,  the  superior 
and  the  inferior  frontal  sulci,  which  divide  this  portion  of  the 
frontal  lobe  into  four  important  convolutions:  the  precentral  or 
ascending  frontal  convolution,  which  is  immediately  in  front  of 


THE   CEREBRUM  85 

the  fissure  of  Rolando,  the  superior,  the  median,  and  the  inferior 
frontal  convolutions. 

The  posterior  part  of  the  left  inferior  frontal  convolution, 
surrounding  the  ascending  limb  of  the  fissure  of  Sylvius,  is  called 
Broca's  convolution.  In  left-handed  individuals  this  name  is 
applied  to  a  similar  portion  of  the  brain  situated  on  the  right 
side.  The  inferior  or  orbital  surface  of  the  frontal  lobe  is 
limited  posteriorly  by  the  fissure  of  Sylvius,  and  internally  by 
the  great  longitudinal  fissure.  It  is  divided  by  the  sulcus 
orbitalis  into  three  convolutions.  These  are  prolongations  of 
the  convolutions  of  the  outer  surface  on  the  inferior  surface  of 
the  frontal  lobe.  Near  the  central  line  is  the  olfactory  groove, 
which  lodges  the  olfactory  bulb  and  its  peduncle. 

The  Olfactory  Lobe. — This  lobe  consists  of  the  olfactory 
bulb  and  its  peduncle,  the  olfactory  area  of  Broca,  the  trigonum 
olfactorium,  and  the  anterior  perforated  space.  The  olfactory 
bulb  is  a  club-shaped  body,  which  gives  off  numerous  nerve- 
fibers  that  pierce  the  dura  and  cribriform  plate  of  the  ethmoid 
bone.  Posteriorly  it  is  continued  into  its  peduncle,  which, 
traced  backward,  divides  into  two  white  bands,  the  outer  passing 
toward  the  fissure  of  Sylvius,  and  the  inner  running  to  the  side 
of  the  longitudinal  fissure.  Between  these  two  limbs  is  a  small 
elevation  called  the  trigonum  olfactorium,  or  the  middle  root 
of  the  olfactory  peduncle.  The  area  lying  anterior  and  internal 
to  the  inner  limb  is  known  as  the  olfactory  area  of  Broca.  The 
anterior  perforated  space  is  the  area  situated  between  the  ex- 
ternal and  the  internal  limb  of  the  olfactory  peduncle  (Fig.  45). 

The  parietal  lobe  is  situated  immediately  posterior  to  the 
frontal  lobe,  from  which  it  is  separated  by  the  fissure  of  Rolando. 
Internally  it  is  limited  by  the  great  longitudinal  fissure,  and 
posteriorly  the  parieto-occipital  fissure  separates  it  from  the 
occipital  lobe.  Inferiorly  the  fissure  of  Sylvius  separates  it 
from  the  temporal  lobe.  Its  posterior  lateral  surface  is  not 
separated  •  from  the  occipital  lobe  by  a  definite  fissure;  its 
lateral  surface  is  marked  by  two  distinct  fissures — the  post- 
central fissure,  which  is  parallel  to  the  fissure  of  Rolando,  and 
the  intraparietal  fissure,  which  arches  from  before  backward, 
and   frequently    communicates   with    the   postcentral   fissure. 


86  MANUAL   OF   NERVOUS   DISEASES 

These  fissures  divide  the  lateral  surface  of  the  parietal  lobe  into 
three  well-marked  divisions — the  postcentral  convolution, 
situated  posterior  to  the  fissure  of  Rolando;  the  superior  and 
inferior  parietal  lobules,  situated  above  and  below  the  intra- 
parietal  fissure.  The  inferior  parietal  lobule  is  further  divided 
into  three  parts — an  anterior  part,  arched  around  the  posterior 
end  of  the  fissure  of  Sylvius,  is  called  the  supramarginal  gyrus; 
a  middle  part,  known  as  the  angular  gyrus,  which  arches  around 
the  posterior  end  of  the  superior  temporal  fissure,  and  a  posterior 
part,  called  the  postparietal  gyrus,  which  is  posterior  to  the 
angular  gyrus. 

The  Occipital  Lobe. — This  lobe  is  pyramidal  in  shape,  with 
its  apex  directed  backward.  It  occupies  the  posterior  portion 
of  the  hemisphere,  and  has  three  surfaces:  an  external,  an  internal, 
and  an  inferior.  The  external  and  internal  surfaces  are  sepa- 
rated from  the  parietal  lobe  by  the  parieto-occipital  fissure  and 
by  a  line  projected  downward  from  this  fissure  across  the  ex- 
ternal surface  of  the  hemisphere.  The  lower  anterior  and  infe- 
rior surfaces  of  his  lobe  are  not  distinctly  separated  from  the 
parietal  and  temporal  lobes.  The  outer  surface  is  divided  by 
two  longitudinal  fissures  into  a  superior,  a  middle,  and  an  infe- 
rior occipital  convolution. 

The  temporal  lobe  occupies  the  middle  fossa  of  the  skull. 
It  is  conical  in  shape,  and  presents  three  surfaces:  an  upper,  a 
lower,  and  an  external  or  lateral.  The  temporal  lobe  is  sepa- 
rated from  the  parietal  lobe  by  the  fissure  of  Sylvius.  The 
external  surface  is  limited  above  by  this  fissure  and  below  by 
the  inferior  temporal  sulcus.  Posteriorly,  this  surface  fuses 
with  the  occipital  lobe.  It  is  marked  by  three  anteroposterior 
fissures — the  superior,  the  middle,  and  the  inferior — which 
separate  this  surface  into  a  superior,  middle,  and  inferior 
temporal  convolution.  The  upper  surface  is  hidden  within  the 
fissure  of  Sylvius.  The  inferior  surface  presents  posteriorly  a 
transverse  depression,  which  serves  as  a  dividing  line  between  the 
temporal  and  occipital  lobes.  The  inferior  surfaces  of  the  tem- 
poral and  occipital  lobes  are  separated  into  a  superior  and  an 
inferior  occipitotemporal  convolution ;  these  are  separated  from 
each  other  by  the  collateral  fissure. 


THE    CEREBRUM 


87 


The  central  lobe,  or  island  of  Reil,  lies  deeply  within  the 
hssure  of  Sylvius.  It  is  pyramidal  is  shape,  and  consists  of 
five  or  six  convolutions. 

The  Fissures  and  Convolutions  of  the  Median  Surface  of  the 
Hemispheres. — Fissure  of  the  Corpus  Callosum. — This  fissure 
commences  in  front,  below  the  anterior  end  of  the  corpus 
callosum.  It  runs  along  the  upper  margin  of  this  structure, 
turns  around  its  posterior  extremity  along  the  inner  border  of  the 
temporal  lobe,  and  extends  to  the  notch  of  the  uncus  (Fig.  43). 


J  tJy' 


Fig.  43. — Fissures  and  convolutions  of  the  median  surface  of  the  hemispheres. 

The  callosomarginal  fissure  commences  in  front,  beneath  the 
anterior  end  of  the  corpus  callosum.  It  first  extends  forward, 
and  then  runs  upward  and  backw^ard,  parallel  to  the  margin  of 
the  hemisphere.  It  lies  between  the  fissure  of  the  corpus  callo- 
sum and  the  upper  margin  of  the  hemisphere,  and  extends  back- 
ward to  a  point  corresponding  to  about  the  posterior  end  of  the 
corpus  callosum,  where  it  turns  upward  to  the  upper  border  of 
the  hemisphere,  a  little  behind  the  fissure  of  Rolando.  This 
fissure  limits  the  extent  of  the  frontal  lobe  on  the  median  sur- 
face of  the  hemisphere. 

The  fissura  subparietalis  is  the  continuation  of  the  callosomar- 


88  MANUAL   or   NERVOUS   DISEASES 

ginal  fissure  from  the  point  where  it  turns  upward.  This 
fissure  marks  the  Hmit  of  the  parietal  lobe  on  the  median  aspect 
of  the  hemisphere. 

The  parieio-occipital  fissure  is  well  marked  on  the  median 
aspect  of  the  hemisphere.  It  is  directed  downward  and  for- 
ward, and  merges  with  the  calcarine  fissure.  It  separates  the 
median  surface  of  the  parietal  lobe  from  the  median  aspect  of 
the  occipital  lobe,  and  is  continued  for  a  short  distance  over  on 
the  lateral  aspect  of  the  cerebral  hemisphere. 

The  calcarine  fissure  is  a  well-marked  depression  upon  the 
median  aspect  of  the  occipital  lobe.  It  runs  forward  and  slightly 
upward  from  the  posterior  border  of  the  hemisphere  to  join  the 
parieto-occipital  fissure. 

The  hippocampal  or  dentate  fissure  is  that  p6rtion  of  the  fissure 
of  the  corpus  callosum  w^hich  occupies  the  internal  surface  of  the 
temporal  lobe. 

Convolutions  of  the  Median  Aspect  of  the  Hemispheres. — 
Situated  in  front  of  and  above  the  callosomarginal  fissure  is  the 
marginal  convolution,  which  forms  the  median  aspect  of  the 
frontal  lobe.  The  posterior  part  of  this  convolution  in  front  of 
the  ascending  limb  of  the  callosomarginal  fissure  is  called  the 
paracentral  convolution.  Situated  between  the  ascending  limb 
of  the  callosomarginal  fissure  and  the  parieto-occipital  fissure, 
above  the  subparietal  fissure,  is  the  praecuneus,  or  quadrate 
lobule,  w^hich  represents  the  median  aspect  of  the  parietal  lobe. 
Between  the  parieto-occipital  fissure  and  the  calcarine  fissure 
lies  the  cuneus,  or  wedge-shaped  convolution,  which  represents 
a  portion  of  the  median  aspect  of  the  occipital  lobe. 

The  gyrus  fornicatus,  gyrus  cinguli,  or  convolution  of  the  corpus 
callosum,  commences  in  front,  below  the  anterior  end  of  the 
corpus  callosum.  It  arches  upward  and  backward,  then  around 
the  posterior  end  of  the  corpus  callosum,  where  it  becomes 
slightly  constricted  and  is  here  called  the  isthmus.  It  then  runs 
downward  and  forward  on  the  internal  aspect  of  the  temporal 
lobe  as  the  gyrus  hippocampi,  or  superior  occipitotemporal 
convolution,  ending  in  front  in  the  uncus  of  the  temporal  lobe. 
This  group  of  convolutions,  together  with  the  structures  included 
within  their  zone,  forms  the  limbic  lobe. 


THE    CEREBRUM 


89 


Fusiform 
sslL 


Triangular 

cell., 


Polygonal 


Z^Pia  mater. 


Large  ;; 

idol  cell.    1 1 


Layer  of 
small 


Layer  of 
large 

Pyramidal 
cells. 


SA 


Layer  of 
poly 

morphaus 
ceUs. 


Polymorphous  layer,  [ 


Fig.  44. — Microscopic  structure  of  the  cortex  of  the  cerebrum.     (Whitaker, 
"Anatomy  of  the  Brain  and  Spmal  Cord,"  after  Ramon  y  Cajal.) 

The  Structure  of  the  Cortex  of  the  Cerebrum  (Fig.  44). — The 
gray  matter  of  the  cerebral  cortex  is  arranged  in  several  more 


go  MANUAL   OF   NERVOUS  DISEASES 

or  less  distinct  layers.  These  are  composed  of  nerve-cells  and 
nerve-fibers,  neuroglia,  blood-vessels,  and  lymphatics.  There  are 
four  more  or  less  distinct  layers  of  the  cortex  which  are  character- 
ized by  definite  types  of  cells:  (i)  The  molecular  layer,  which 
contains  many  neuroglia  cells,  polygonal,  fusiform,  and  triangu- 
lar cells.  The  axis-cylinder  processes  of  these  cells  are  almost 
entirely  confined  to  this  layer.  (2)  A  layer  of  small  pyramidal 
cells.  (3)  A  layer  of  large  pyramidal  cells,  called  the  cells  of 
Betz.  These  cells  are  large,  thin  axis-cylinder  processes,  de- 
scending, and  in  the  upper  part  of  their  course  giving  off  many 
branches.  The  process  then  descends,  and  ultimately  ends  in 
the  gray  matter  at  the  lower  levels.  (4)  A  layer  of  polymorphous 
cells.  In  this  layer  the  cells  vary  much  in  size  and  shape.  In 
the  second,  third,  and  fourth  layers  are  also  found  the  cells  of 
Golgi  and  the  cells  of  Martinotti. 

The  character  and  type  of  cells  vary  in  different  regions  of 
the  cerebral  cortex.  In  some  regions  eight  distinct  layers  may 
be  recognized,  whereas  in  others  it  is  difficult  accurately  to 
identify  four  layers. 

The  white  and  gray  fibers  found  in  the  cortex  are  the  processes 
of  the  nerve-cells  of  the  cortex  and  of  those  that  have  ascended 
from  lower  levels. 

Neuroglia  pervades  the  entire  cortex,  and  is  specially  well 
marked  along  the  blood-vessels  and  immediately  beneath  the 
pia. 

THE  UNDER  ASPECT  OF  THE  CEREBRUM 

The  under  aspect  of  the  brain  is  irregular  in  shape.  It 
presents  for  examination  the  cerebellum;  the  medulla;  the  pons 
Varolii;  the  cerebral  peduncles;  the  inferior  aspect  of  the  frontal 
and  temporal  lobes;  the  anterior  part  of  the  great  longitudinal 
fissure;  the  internal  portion  of  the  fissure  of  Sylvius;  the  circle 
of  Willis;  the  interpeduncular  space;  and  the  superficial  origins 
of  the  cranial  nerves. 

A  careful  study  of  the  accompanying  illustration  (Fig.  45) 
will  reveal  the  relation  of  these  various  structures  to  one  an- 
other. Each  of  the  structures  has  been  or  will  be  described 
under  its  appropriate  head. 


THE    UNDER   ASPECT    OF    THE    CEREBRUM 


91 


The  interpeduncular  space  is  an  irregular  area  at  the  base  of 
the  brain,  situated  between  the  great  longitudinal  fissure  ante- 
riorly, the  under  surface  of  the  frontal  and  temporal  lobe  on  each 
side,  and  the  cerebral  peduncle  posteriorly.  This  irregular- 
shaped  interval  is  formed  by  a  thin  layer  of  gray  and  white 
matter  stretching  across  the  middle  line,  uniting  the  under 
surface  of  the  two  hemispheres. 


Great  U>nijitv4iiial 


Lamina  terminalis. 


Iakus  perfirratus 
antU'its. 


iifundibvium. 

Tuber  einerenv 

Corpora 
■iaimnillario 


•2  (chiixsnui 
extract. 


SpivaJ  rni.t    ! 


Fiff.  4=;  —Base  of  the  brain.     (Whitaker,  "Anatomy  of  the  Brain  and  Spinal 

Cord.") 

The  anterior  perforated  space  is  a  grayish  lamina,  perforated 
for  the  passage  of  blood-vessels  uito  the  brain.  It  is  situated 
external  to  the  optic  commissure,  at  the  root  of  the  fissure  of 
Sylvius,  behind  and  between  the  roots  of  the  olfactory  pedun- 
cles.    Externally  it  is  continuous  with  the  hemispheres. 


92  MANUAL   OF   NERVOUS  DISEASES 

The  posterior  perforated  space,  called  also  the  pons  Tarini, 
is  a  gray  lamina,  similar  to  the  anterior  perforated  space,  and, 
like  it,  perforated  for  the  passage  of  blood-vessels  into  the  in- 
terior of.  the  cerebrum.  It  is  situated  between  the  diverging 
cerebral  peduncles,  and  posterior  to  the  tuber  cinereum. 

The  Pituitary  Body,  or  Hypophysis  Cerebri. — This  gland  is 
oval  in  shape,  and  has  a  reddish  color.  It  consists  of  two  por- 
tions— the  anterior  lobe,  w^hich  is  made  up  of  a  network  of 
connective  tissue  and  of  epithelial  cells,  and  is  developed  origin- 
ally from  the  buccal  cavity;  and  a  posterior  lobe,  which  consists 
of  a  network  of  fine  nerve-fibers,  connective  tissue,  and  neuroglia. 
The  posterior  lobe  is  developed  originally  from  the  anterior 
cerebral  vesicle,  and  is  connected  with  the  third  ventricle  by 
the  infundibulum.  Between  the  anterior  and  posterior  lobes, 
and  connecting  them,  is  the  pars  intermedia.  In  the  pars 
intermedia  are  found  cells  that  secrete  a  colloid  substance, 
resembling  in  appearance  the  characteristic  secretion  of  the 
thyroid  gland.  The  posterior  lobe  is  poorly  supplied  with 
blood-vessels,  whereas  the  anterior  lobe  is  highly  vascular. 

The  corpora  albicantia  are  rounded,  pea-shaped  nodules, 
situated  in  front  of  the  posterior  perforated  space,  between  it 
and  the  tuber  cinereum.  These  small  white  bodies  are  connected 
wdth  the  fornix. 

The  Tuber  Cinereum. — This  is  a  somewhat  irregular-shaped 
elevation,  situated  anterior  to  the  corpora  albicantia.  Project- 
ing downward  from  the  tuber  cinereum  is  a  funnel-shaped 
process  called  the  infundibulum.  Attached  to  its  inferior  end 
is  an  egg-shaped  gray  mass,  the  hypophysis  cerebri,  which  is 
situated  in  the  sella  turcica.  The  posterior  lobe  of  this  gland 
is  alone  connected  with  the  infundibulum. 

The  Optic  Chiasm  or  Commissure  and  the  Optic  Tracts. — The 
optic  commissure  is  quadrilateral  in  form,  and  rests  upon  the 
optic  groove  of  the  sphenoid  bone.  On  either  side  of  the  optic 
commissure  is  the  anterior  perforated  space,  and  posterior  to  it 
is  the  tuber  cinereum.  Within  the  commissure  the  optic  ner\"es 
of  the  two  sides  undergo  partial  decussation.  Anteriorly,  the 
optic  commissure  divides  into  the  two  optic  nerves,  which  be- 
come rounded,  and  are  inclosed  in  a  sheath  derived  from  the 


INTERIOR   OF    THE    CEREBRUM  93 

arachnoid,  which  is  covered  by  a  sheath  from  the  dura.  The 
optic  nerves  pursue  an  anterior  course,  and  enter  the  orbit 
through  the  optic  foramina. 

The  optic  tracts  are  two  well-marked,  flattened  bundles  of 
fibers  that  are  given  off  from  the  posterior  portion  of  the  optic 
commissure.  They  run  backward  and  outward,  passing  obliquely 
across  the  surface  of  the  crusta  in  the  form  of  a  flattened  band. 
They  then  divide  into  two  parts— an  external  and  an  internal. 
The  external  part  enters  the  external  geniculate  body  and  the 
under  surface  of  the  pulvinar  of  the  optic  thalamus;  it  receives 
most  of  the  fibers  of  the  brachium  of  the  superior  corpora 
quadrigemina.  The  internal  division  enters  the  internal  genic- 
ulate body,  from  which  it  derives  its  fibers. 

As  has  been  stated,  the  optic  nerves  of  the  two  sides  undergo 
a  partial  decussation  within  the  optic  commissure.  The  fibers 
that  form  the  inner  margin  of  each  tract  are  continued  across 
from  one  side  of  the  brain  to  the  other  (commissure  of  Gudden) . 
The  outer  fibers  of  each  tract  are  continued  into  the  optic  nerve 
of  the  same  side.  The  central  fibers  of  each  tract  are  continued 
through  the  commissure  to  the  optic  nerve  of  the  opposite  side. 

INTERIOR  OF  THE   CEREBRUM 

Upon  section  of  the  brain  the  following  structures  are  en- 
countered: Immediately  beneath  the  cortex  the  hemispheres 
consist  of  a  mass  of  white  tissue  that  is  made  up  of  meduUated 
fibers  of  varying  size.  They  may  be  divided  into  three  distinct 
systems,  according  to  the  course  which  they  pursue:  projection 
fibers,  commissural  fibers,  and  association  fibers.  Cavities, 
which  are  called  ventricles,  and  collections  of  gray  masses,  the 
basal  ganglia,  are  also  seen  (Fig.  46). 

The  ventricles  of  the  brain  are  five  in  number.  They  are  the 
remains  of  the  neural  canal,  from  the  walls  of  which  the  brain  and 
the  spinal  cord  are  developed.  Upon  coronal  section  they  are 
seen  to  be  somewhat  T  shaped.  The  ventricles,  with  the  ex- 
ception of  the  fifth,  communicate  with  one  another  and  with  the 
subarachnoid  space. 

The  lateral  ventricles,  or  first  and  second  ventricles,  are  two 
irregular,  crescent-shaped  cavities,  hollowed  out  in  the  sub- 


94 


MANUAL   OF   NERVOUS   DISEASES 


stance  of  the  cerebral  hemisphere.  Each  of  these  ventricles 
consists  of  a  central  part,  the  body,  and  of  three  prolongations — 
the  anterior,  the  posterior,  and  the  descending  or  lateral  horns. 
The  roof  is  formed  by  the  corpus  callosum,  and  the  floor  by  a 
small  part  of  the  corpus  callosum,  the  nucleus  caudatus,  the 
optic  thalamus,  the  stria  terminalis,  the  choroid  plexus,  and  the 
free  edge  of  the  body  of  the  fornix.     In  front,  the  inner  wall  of 


iil;l^^    -,  ..^If^"^ 


Cai.snla  ii.;^rt,ii 


nadiaiio  curjinth  Mii:>ii 


yu.lLil-   U"-*!;: 


IN  tb-jjaiui 

\      Iliabuominill 
VI.. I  cl'A 


i     .         Ma-. 


Fig.  46. — Section  through  the  brain  in  direction  of  the  cerebral  peduncles. 

(After  Spalteholz.) 


the  ventricle  is  formed  by  a  thin,  double,  vertical  triangular 
partition,  the  septum  lucidum,  which  extends  between  the  under 
surface  of  the  corpus  callosum  and  the  upper  surface  of  the 
fornix.  Externally  the  floor  and  roof  meet,  so  that  there  is  no 
outer  wall  (Fig.  47). 

The  anterior  horn  is  short,  and  turns  forward  and  outward 
from  the  anterior  part  of  the  body  of  the  ventricle  into  the  sub- 
stance of  the  frontal  lobe. 


INTERIOR   OF    THE    CEREBRUM 


95 


The  posterior  horn  passes  backward,  outward,  and  inward 
into  the  substance  of  the  occipital  lobe.  On  the  floor  of  this 
horn  is  an  oval  prominence  called  the  hippocampus  minor,  caused 
by  the  calcarine  fissure.     Above  this  is  a  slight  ridge,  produced 


c.c. 


Fig.  47. — Lateral  ventricle:  5th  V.,  Fifth  ventricle;  X.C.,  nucleus  cauda- 
tus;  C.P.,  choroid  plexus;  O.T.,  optic  thalamus;  F.,  fornix;  C.C,  corpus  cal- 
losum;  P.C.,  posterior  comu;  S.T.,  stria  terminahs;  S.L.,  septum  lucidum; 
P.H.,  pes  hippocampi;  H.Ma.,  hippocampus  major;  T.H.,  tinea  hippo- 
campi; C.F.,  crura  fomicis;  E.C.,  eminentia  collateralis;  H.Mi.,  hippo- 
campus minor.     (WTiitaker,  "i\natomy  of  the  Brain  and  Spinal  Cord.") 


by  radiating  bundles  of  the  corpus  callosum,  and  known  as  the 
forceps  minor. 

The  lateral,  descending,  or  inferior  horn  curves  around  the 
posterior  end  of  the  optic  thalamus,  runs  backward,  outward, 
and  then  downward  and  forward,  and  finally  turns  inward  in 
the  substance  of  the  temporal  lobe.     In  the  floor  of  this  horn  is 


96 


MANUAL   OF   NERVOUS   DISEASES 


an  elongated  projection  following  the  bend  of  the  horn,  and 
called  the  hippocampus  major.  This  elevation  is  caused  by  the 
hippocampal  fissure.  The  choroid  plexus  of  the  lateral  ventricle 
projects  into  this  horn. 

The  lateral  ventricles  are  lined  by  a  layer  of  gray  matter, 
covered  on  the  surface  by  columnar  ciliated  epithelium,  which 
is  continuous  with  the  epithelium  of  the  other  ventricles. 


Body  of  corpus  caJlosum 


Lam  I  fid  of  septum  p^llucldum 


Genu  of  corpus — /§ 
c  alios  urn  (== 

Rostrum  of.^_^ 
corpus  callosum 


Mi 


Lamina  ierminalis 
Optic  chiastna. 


Body  of  fornix 

Iniermedlaie  mass 

Tela  chorioidea  of  ventricle  IS 

Thalamus 

Third  verilr'icle 
Habenular  Irigone 
Vosterior  commisure 

■Pineal  body 

Splenium  df  corpus  callosum 
Lamina  ouadrigemina. 

Fourth  Ventricle 


Hypophysis  - 
Mam  miliary  body ' 

Cerebral  peduncle     \^    T^^i 

Pons-^^r]Mz 

IVIedulla  ablon^atc 


Gyri  of  vermis 


Cerebellum. 


Spinal  cord 


Medullary  substance 
of  vermis 


Fig.  48. — Median  section  of  the  brain  without  the  hemispheres. 


The  Foramen  of  Monro. — Between  the  fornk  in  front  and 
the  optic  thalami  behind  is  a  slit-like  opening  by  means  of  which 
the  lateral  ventricles  communicate  with  the  third  ventricle,  and 
indirectly  with  each  other;  this  is  called  the  foramen  of  Monro. 
Through  this  foramen  the  choroid  plexus  of  the  lateral  ventricle 
is  continuous  with  that  of  the  third  ventricle. 

The  third  ventricle  is  a  narrow,  vertical  cleft,  situated  in  the 


INTERIOR   OF    THE    CEREBRUM 


97 


middle  line  of  the  cerebrum,  between  the  two  optic  thalami. 
It  lies  beneath  the  body  of  the  fornix,  and  extends  down  to  the 
base  of  the  brain,  being  deeper  in  front  than  behind.  Its  roof 
is  formed  by  the  under  surface  of  the  velum  interpositum,  which 


Fig.  49. — Third  ventricle,  from  above:  A.Cor.,  anterior  comu;  jth'V.,  fifth 
ventricle;  N.C.,  nucleus  caudatus;  S.T.,  stria  terminalis;  jrd  V.,  third  ven- 
tricle; O.r.,  optic  thalamus;  P. 5.,  pineal  body;  C.().,  corpora  quadrigemina; 
V.C.I. ,  ven£e  cerebri  internse;  Cr.F.,  crura  fornicis;  C.C.,  corpus  callosum; 
S.L.,  septum  lucidum;  Col.F.,  columnas  fornicis;  A.C.,  anterior  commissure; 
M.I.,  massa  intermedia;  P.C.,  posterior  commissure;  P.,  pulvinar;  V.I., 
velum  interpositum;  C.P.,  choroid  plexus;  P. Cor.,  posterior  cornu.  (Whit- 
aker,  "Anatomy  of  the  Brain  and  Spinal  Cord.") 


is  covered  by  a  layer  of  flattened  epithelial  cells.  Its  floor  is 
formed  by  the  dorsal  part  of  the  cerebral  peduncles,  the  posterior 
perforated  space,  the  corpora  albicantia,  the  tuber  cinereum,  the 
infundibulum,  and  the  optic  chiasm.  In  front,  the  ventricle 
is  limited  by  the  anterior  pillars  of  the  fornix,  and  behind  it 
7 


98  MANUAL   OP   NERVOUS   DISEASES 

opens  into  the  aqueduct  of  Sylvius.  The  lateral  walls  are  formed 
by  the  inner  surfaces  of  the  optic  thalami.  Across  the  center 
of  the  third  ventricle,  between  the  optic  thalami,  is  a  small  gray 
band  called  the  middle  or  gray  commissure.  The  third  ventricle 
is  lined  by  epithelium  similar  to  and  continuous  with  that  of  the 
other  ventricles.  Hanging  from  the  roof  along  the  middle  line, 
from  the  under  surface  of  the  velum  interpositum,  are  the  folds 
of  the  choroid  plexuses.  The  third  ventricle  communicates  in 
front  and  above,  through  the  foramen  of  Monro,  with  the  lateral 
ventricles;  posteriorly,  through  the  aqueduct  of  Sylvius,  with  the 
fourth  ventricle;  in  the  anterior  part,  through  a  conical-shaped 
passage  in  the  floor,  with  the  infundibulum  (Figs.  48  and  49). 

The  septum  lucidum  is  a  thin,  double,  vertical  partition, 
which  separates  the  lateral  ventricles  from  each  other.  It  is 
triangular  in  shape,  and  fills  up  the  interval  between  the  inner, 
knee-shaped  bend  of  the  corpus  callosum  and  the  anterior  pillars 
of  the  fornix.  Its  apex  is  directed  posteriorly.  Between  its  two 
layers  is  a  narrow,  slit-like  cavity,  called  the  fifth  ventricle.  On 
the  internal  surface  of  each  lamina  of  the  septum  is  a  thin  layer 
of  gray  matter,  and  on  the  exterior  surface,  next  to  the  cavity  of 
the  lateral  ventricles,  is  a  layer  of  white  matter  covered  by  the 
neuroglia  and  epithelium.  The  cavity  of  the  fifth  ventricle  is 
not  lined  by  epithelium,  and  does  not  communicate  with  any  of 
the  other  ventricles  (Fig.  48). 

The  velum  interpositum  is  a  fold  of  pia  mater  that  enters 
the  brain  through  the  great  transverse  fissure  of  the  cerebrum, 
appearing  in  the  third  and  lateral  ventricles.  It  is  covered  by 
ependymal  epithelium.  It  is  triangular  in  shape,  with  its  apex 
directed  forward,  and  reaches  from  the  foramen  of  Monro  in 
front  to  the  back  part  of  the  splenium  of  the  corpus  callosum, 
beneath  which,  after  investing  the  pineal  gland,  it  is  continuous 
with  the  pia  mater  of  the  cerebrum  and  cerebellum. 

At  the  sides,  the  free  edges  of  the  velum  interpositum  project 
into  the  floor  of  the  lateral  ventricles,  and  rest  on  the  upper 
surfaces  of  the  optic  thalami,  passing  into  the  descending  horns 
of  the  lateral  ventricles.  In  each  lateral  margin  of  the  velum 
interpositum  are  vascular  fringes  that  consist  of  tortuous  ramifi- 
cations of  small  blood-vessels,  forming  the  choroid  plexuses  of 


INTERIOR    OF    THE    CEREBRUM 


99 


the  lateral  ventricles  which  extend  to  the  apices  of  the  descend- 
ing horns.  As  these  vascular  fringes  pass  backward  they  send 
a  projection  into  the  posterior  horns.  They  are  continuous 
through  the  foramen  of  Monro  into  the  third  ventricle,  project- 
ing downward,  along  the  middle  line  of  the  under  aspect  of  the 
velum  interpositum,  to  form  the  choroid  plexuses  of  the  third 
ventricle  (Fig.  50). 


Fig. 


50. — Horizontal   section  of    cerebral   hemispheres;    fornix  has  been 
reflected  to  show  the  velum  interpositum. 


The  intemal  cerebral  veins  are  two  veins  that  gather  up  the 
blood  from  the  choroid  plexuses  and  the  basal  ganglia,  and  run 
backward  side  by  side  between  the  layers  of  the  velum  inter- 
positum. They  unite  to  form  the  vein  of  Galeni,  which  enters 
the  straight  sinus. 

The  great  transverse  fissure  of  the  brain  is  horseshoe  shaped, 
its  central  portion  corresponding  to  the  base  of  the  fornix,  and 
its  lateral  part  to  the  descending  horns  of  the  lateral  ventricles. 


lOO 


MANUAL   OF   NERVOUS   DISEASES 


Through  this  fissure  the  pia  mater  and  choroid  plexuses  project 
into  the  ventricles. 

The  Basal  Ganglia. — These  are  large  gray  masses  situated  at 
the  base  of  the  brain.  The  corpora  striata  are  two  in  number,  one 
in  each  hemisphere.  Each  corpus  is  divided  into  two  parts — an 
intraventricular  portion  and  an  extraventricular  portion.     The 


Gyrus  fornicatus 
Corpus  Cal/osum 


jSepfum y_ 

lucidum 
Corpus 
striaTuni  Wu   / 

/Inferior         '///■    / 
Pi  liar  of 
Fornix 

Tenia  Semi^ 
Circularis 


Optic 


Thalamus 


Corporci. 
Quadri^emincL 

Superior  Peduncle 
of  Cerebellum 

Inferior  Peduncle 
Middle  Peduncle 

Ala  Cinerea 

Obex 


AnieriorCornu 


Caudate  Nucleus 

Internal  Capsule 
(anTerior  limb) 
External  Capsule 
L  enticular  Nucleus 
Clausfrum 

.  'nternal  capsule 
(posterior  limb) 

Optic  Thalamus 

or  pus  Geniculatum 
Internum 

Caudate  Nucleus 

Hippocampus 

major 
'Jiippo.  campus 

minor 


ClavcL 

Funiculus  Cuneatus 

Funiculus  Cracilis 

Fig.  51. — Horizontal  section  of  cerebrum,  showing  basal  ganglia,  optic 

thalamus,  etc. 


nucleus  caudatus,  the  intraventricular  portion  of  the  corpus 
striatum,  is  pear  shaped,  and  has  a  pinkish-gray  color.  It 
consists  of  a  gray  core  streaked  with  white  fibers,  and  covered 
on  the  surface  by  layers  of  white  substance.  Its  larger  end  or 
head  is  directed  forward,  gradually  tapering  as  it  passes  back- 
ward to  the  outer  side  of  the  optic  thalamus,  where  it  turns  down- 


INTERIOR    OF    THE    CEREBRUM  lOI 

ward,  outward,  and  forward  into  the  roof  of  the  descending  horn 
of  the  lateral  ventricle.  It  can  be  traced  as  far  forward  as  the 
tip  of  the  temporal  lobe.  In  its  course  it  forms  an  arch  with  its 
concavity  directed  forward. 

The  lenticular  nucleus,  the  extraventricular  part  of  the  corpus 
striatum,  is  placed  externally  to  both  the  caudate  nucleus  and 
the  optic  thalamus,  being  separated  from  them  by  a  strand  of 
white  nerve-fibers  called  the  internal  capsule.'  On  horizontal 
section  it  is  seen  to  be  shaped  like  a  double  convex  lens.  It  is 
divided  vertically  by  two  white  lamina  into  three  parts — an 
internal,  a  middle,  and  an  external.  These  differ  somewhat  in 
color,  the  internal  and  middle  portions,  being  of  a  paler  hue,  are 
called  the  globus  palUdus.  The  external  portion  is  called  the 
piitamen.  In  front  and  below  the  caudate  nucleus  and  the 
lenticular  nucleus  are  continuous  with  each  other  and  with  the 
gray  matter  of  the  anterior  perforated  space  (Fig.  51). 

The  optic  thalami  are  two  large,  oval  prominences,  situated 
above  the  cerebral  peduncles,  behind  and  internal  to  the  corpora 
striata.  Each  optic  thalamus  consists  of  a  central  gray  core 
covered  by  a  stratum  of  white  matter.  Each  thalamus  has  four 
surfaces  and  two  ends.  The  anterior  end  is  rounded,  and  the 
posterior  end  swells  out  into  a  prominence  called  the  pulvinar. 
The  gray  matter  of  the  optic  thalami  is  arranged  as  three  nu- 
clei— anterior,  outer,  and  inner  (Figs.  51  and  52). 

Functions. — ^These  ganglia,  together  with  the  corpora  striata, 
are  very  probably  intermediate  stations  for  the  transmission  of 
sensation  and  motion.  They  also  exert  some  influence  on  the 
reflex  activities  of  the  body,  and  it  is  highly  probable  that  it  is 
through  these  structures  that  the  complicated  and  instantaneous 
reflexes  that  occur  as  a  consequence  of  visual  and  auditory 
stimulation  take  place. 

The  Geniculate  Bodies. — Below  and  external  to  the  pulvinar 
of  each  optic  thalamus  are  two  oval  prominences — the  internal 
and  external  geniculate  bodies.  The  internal  body  is  smaller, 
and  is  separated  from  the  external  by  a  band  of  white  fibers 
which  is  one  of  the  roots  of  the  optic  tract. 

The  geniculate  bodies  consist  of  a  gray  core  and  a  white  cortex. 
The  external  geniculate  body  is  connected  by  a  band  of  fibers  to 


I02 


MANUAL   OF   NERVOUS   DISEASES 


the  anterior,  and  the  internal  geniculate  body  to  the  posterior, 
corpora  quadrigemina.  The  external  geniculate  body  is  also 
connected  with  the  optic  tracts. 

The  pineal  gland  is  a  reddish,  vascular,  oval  body,  situated  in 
the  anterior  part  of  the  longitudinal  groove,  between  the  superior 
corpora  quadrigemina.  It  is  composed  of  follicles  separated  by 
connective  tissue,  and  filled  with  epithelial  cells  and  calcareous 
particles  (Figs.  52  and  53). 


Cauddte.  nucleus  Laminae  of  septum  pellucidum 


Columns  of  fornix 


Cau'iti/  of3<^  ventricle 
OpTic  fhalamus 
Pinealgland. 

■Sup.  corpora  ouad. 

In  f.  corpora  cfuad. 
^i^  nerve 
Supcerebelloj- peduncle 


Crus  cerebri 


Tela  chorioidei 
of  H-tf  ventricle 


Middle  cerebellar 
peduncle 


CavlN  of 4^'' ventricle 


Foramen  of  A/faff  endle 

Fig.  52. — The  thalami,  the  epithalamus,  the  lamina  quadrigemina,  and  the 
rhombencephalon,  seen  from  behind  and  above,  after  removal  of  the  greater 
part  of  the  cerebellum. 


The  corpus  callosum  is  a  longitudinal  band  of  transverse 
fibers  that  arches  from  before  backward,  in  the  middle  line,  be- 
tween the  two  cerebral  hemispheres,  which  it  connects.  It  is 
about  four  inches  long,  and  forms  the  floor  of  the  great  longi- 
tudinal fissure.  It  approaches  the  anterior  aspect  of  the  brain 
more  nearly  than  the  posterior.  It  is  thicker  at  the  ends  than 
in  the  middle,  and  is  thickest  and  widest  behind.     Anteriorly 


INTERIOR    OF    THE    CEREBRUM 


103 


it  turns  downward  and  backward  upon  itself,  making  a  knee- 
shaped  bend  called  the  genu.  Gradually  becoming  smaller,  it 
forms  a  narrow  median  band,  the  rostrum,  which,  at  the  base 
of  the  brain,  bifurcates  into  two  tapering  processes,  known  as 
the  peduncles  of  the  corpus  callosum.  These  can  be  traced  into 
the  anterior  perforated  spaces  at  the  root  of  the  fissure  of  Sylvius. 
Posteriorly,  it  ends  in  a  thickened,  free,  rounded  border — the 
splenium.     At  the  outer  ends  of  the  splenium  two  horn-shaped 


_  ,     .         ,       PinecJ  body  Post  commiiure  Intermed-mass  of  IhaJamus 
Splenium  of  \  \  \    ^„:=~^s=^=r^ 

Corpus  caJ/asuiT 


od If  of -fornix 


CenbeUum 


Tela  chorioidea. 
or^tiii  ventricle 

Cerebrara^aed^ct°f''^P''Pfy'"' 
^arff.Tneelu/lary  velum 
Medt^XblongaTa.    ■^'^Ventncle 


Lamm,  of  sept, 
'pelluciduin 


Qenuof 
Corpus  CaJ/osum 


Rostrum  of 
jjr  corpus  ca//asum 

Cint.  com fn I  sure 


Optic  chlcum 


'nerve"'         lobe      lobe 


Fig-  53. — Median  section  of  the  brain. 


bundles  of  fibers — the  forceps  major — diverge  into  the  occipital 
lobes  (Fig.  53). 

The  upper  surface  of  the  corpus  callosum  is  covered  by  a  thin 
layer  of  gray  matter.  It  is  marked  in  the  middle  line  by  a 
longitudinal  groove,  the  raphe,  parallel  to  which,  on  each  side, 
are  seen  faint  lines — the  median  longitudinal  striae  or  ner^^es  of 
Lancisi.  External  to  these,  under  the  overhanging  edge  of  the 
gyrus  fornicatus,  are  the  lateral  longitudinal  striae.  The  under 
surface  of  the  corpus  callosum  in  the  middle  line,  in  the  posterior 
half  of  its  extent,  rests  upon  the  body  of  the  fornk,  to  which  it  is 


I04 


MANUAL  OF  NERVOUS  DISEASES 


closely  adherent.  Laterally  the  transverse  fibers  of  the  corpus 
callosum  form  the  roof  of  the  lateral  ventricles,  and  then  spread 
out  into  the  white  substance  of  the  hemispheres  (Fig.  54) . 

The  corpus  callosum  consists  principally  of  transverse  fibers, 
only  a  few  being  longitudinal.  They  pass  into  the  hemispheres, 
diverge  in  all  directions,  go  to  the  gray  matter  of  the  cortex,  and 
connect  similarly  situated  areas  with  each  other. 


ilu  Killgiluaiiialh  lat.-rollr. 
^Iri:i  ^initiliuliuali-  nii-ii 


-ly. 

y^^S 

: 

J^:. 

^  :fe 

Fig.  54. — Corpus  callosum  viewed  from  above  (Spalteholz). 

The  anterior  commissure  is  a  small,  round,  twisted  bundle  of 
transverse  white  fibers  situated  in  front  of  the  anterior  pillars 
of  the  fornix.  It  connects  the  two  olfactory  lobes  and  the  two 
temporal  lobes.     (See  Fig.  48.) 

The  middle  or  gray  commissure  is  a  delicate  band  of  gray 
matter  crossing  the  third  ventricle,  and  connected  with  the  gray 
matter  of  the  optic  thalami.     (See  Fig.  48.) 


INTERIOR   OF    THE    CEREBRUM  I05 

The  posterior  commissure  is  a  small  band  of  white  fibers 
situated  in  front  of  and  below  the  pineal  gland,  above  the 
aqueduct  of  Sylvius.     (See  Fig.  48.) 

The  corpus  callosum  and  the  anterior,  middle,  and  posterior 
commissures  are  the  pathways  which  connect  similarly  situated 
areas  of  the  hemispheres. 

The  fornix  is  an  arched  white  band  that  can  be  traced  from 
the  tip  of  the  descending  horn  of  the  lateral  ventricle  to  the 
corpora  albicantia.  The  fibers  that  go  to  make  up  the  fornix 
arise  as  two  ribbon-like  bands,  one  on  each  side,  from  the  free 
surface  of  the  hippocampus  major.  They  ascend  from  the  free 
surface  of  the  hippocampus  major,  wind  around  the  posterior 
ends  of  the  optic  thalami,  w^here  they  become  the  crura  fornicis. 
They  next  converge  toward  each  other  and  meet  in  the  middle 
line,  to  form  a  white,  flattened,  triangular-shaped  body, — the 
body  of  the  fornix, — which  has  its  apex  directed  forward,  and  is 
blended  above  and  posteriorly  with  the  corpus  callosum.  In- 
feriorly,  it  lies  upon  the  velum  interpositum,  which  separates  it 
from  the  optic  thalami  and  the  third  ventricle.  Its  fibers  then 
diverge  and  go  downward  and  forw^ard  as  two  round,  finger-like 
processes,  called  the  anterior  pillars  of  the  fornix.  These  lie 
side  by  side,  and  can  be  traced  for^^ard  to  the  base  of  the  brain 
to  the  corpora  albicantia.  In  this  position  they  make  a  figure- 
of-8-shaped  twdst  upon  themselves,  forming  the  cortex  of  these 
structures,  and  end  in  gray  matter.  From  cells  in  the  gray 
matter  of  the  corpora  albicantia  new  fibers  arise;  these  are 
termed  the  bundle  of  Vicq  d'Azyr.  The  anterior  pillars  of  the 
fornix,  as  they  descend  in  front  of  the  optic  thalami,  help  to 
form  the  anterior  boundary  of  the  foramen  of  Monro.  The 
body  of  the  fornix  enters  into  the  formation  of  the  floor  of  the 
lateral  ventricles.     (See  Figs.  47  and  48.) 

The  fornix  is  a  tract  of  association-fibers.  These  fibers  con- 
nect different  parts  of  the  same  hemisphere. 

There  are  numerous  other  association-fibers  which  unite 
adjacent  and  distant  convolutions  with  each  other  (Fig.  55). 

The  principal  projection  pathways  are  contained  in  the  internal 
and  external  capsule.    They  are  made  up  of  fibers  that  connect 


io6 


MANUAL   or  NERVOUS   DISEASES 


the  gray  matter  of  the  hemispheres  with  the  lower  part  of  the 
cerebrospinal  axis  (Fig.  56). 

Upon  horizontal  section  the  internal  capsule  appears  as  a 
longitudinal,  semilunar-shaped  band  of  white  matter,  with  its 
concavity  directed  outward.  It  may  be  divided  into  three 
portions — an  anterior,  a  middle,  and  a  posterior.  The  anterior 
division  lies  between  the  caudate  nucleus  internally  and  the 
lenticular  nucleus  externally.    The  posterior  division  lies  be- 


Fig,  55. — Lateral  view  of  a  human  hemisphere,  showing  the  bundles  of 
association-fibers:  A,  A,  Between  adjacent  gyri;  B,  between  frontal  and 
occipital  areas;  C,  between  frontal  and  temporal  areas,  cingulum;  D, 
between  frontal  and  temporal  areas,  fasciculus  uncinatus;  E,  between  oc- 
cipital and  temporal  areas,  fasciculus  longitudinalis  inferior;  C.N.,  caudate 
nucleus;  O.T.,  thalamus  (Starr). 


tween  the  optic  thalamus  internally  and  the  lenticular  nucleus 
externally.  The  anterior  and  posterior  divisions  form  a  sharp 
angle  or  knee.  As  they  ascend,  the  fibers  of  the  internal 
capsule  form  a  radiating,  fan-shaped  group  that  aid  in  the 
formation  of  the  corona  radiata,  which  spreads  out  to  the  cerebral 
cortex  (Figs.  56  and  57). 

Functions  of  the  Internal  Capsule. — The  anterior  limb  is  made 
up  of  fibers  which  ascend  and  descend  from  the  anterior  part  of 
the  frontal  lobe,  to  terminate  or  originate  in  the  gray  matter  of 


INTERIOR    OF    THE    CEREBRUM  107 

the  basal  ganglia  and  the  pons.  The  knee  and  the  anterior 
two-thirds  of  the  posterior  limb  are  made  up  oifibers  which 
arise  in  the  posterior  part  of  the  frontal  lobe,  and  terminate  in 
the  parts  below ;  they  transmit  impulses  that  result  in  voluntary 


Fig.  56. — Schema  of  the  projection  fibers  of  the  cerebrum  and  of  the  pe- 
duncles of  the  cerebellimi;  lateral  \dew  of  the  internal  capsule:  A ,  Tract  from 
the  frontal  gyri  to  the  pons  nuclei,  and  so  to  the  cerebellum  (frontal  cere- 
brocorticopontal  tract);  B,  the  motor  (pyramidal)  tract;  C,  the  sensory 
(lemniscus)  tract;  D,  the  \asual  tract;  E,  the  auditor}^  tract;  F,  the  fibers  of 
the  superior  peduncle  of  the  cerebellum;  G,  fibers  of  the  middle  pedimcle 
uniting  with  A  in  the  pons;  H,  fibers  of  the  inferior  peduncle  of  the  cere- 
bellum; /,  fibers  between  the  auditory  nucleus  and  the  inferior  colliculus; 
K,  motor  (pyramidal)  decussation  in  the  bulb;  Vt.,  fourth  ventricle.  The 
numerals  refer  to  the  cranial  nerves.     (Modified  from  Starr.) 

motion,  and  are  placed  in  the  following  order:  From  before 
backward,  those  that  have  to  do  with  the  muscles  of  the  eyes, 
then  the  mouth  and  tongue,  face,  upper  extermities,  legs,  and 
trunk.  These  fibers  descend  and  influence  structures  situated 
on  the  opposite  side  of  the  crura,  pons,  medulla,  and  spinal  cord. 


io8 


MANUAL   OF   NERVOUS   DISEASES 


Blended  with  these  fibers  are  secondary  motor  pathways  that 
connect  the  central  convolutions  with  the  pontile  nuclei  and  the 
cerebellum  of  the  opposite  side. 

The  posterior  third  of  the  posterior  limb  is  occupied  by  fibers 
that  transmit  sensory  impulses  upward.     Behind  these  fibers 


Lenticula\nuc/eus 


Caudate  nucleus 


Ofiticthalamus 


Puiamen  of  Uniicul'ur. 
nucleus 


Island  of  Ren 


densori^Tn 


Optic,    . 
Hadiat! 


osf.  limb 


Globus 
pcLllidus 


Cereoellum 

Fig.  57. — Horizontal  section  of  the  brain. 


are  fibers  that  connect  the  occipital  and  temporal  lobes  with  the 
pontile  nuclei,  the  optic  thalamis,  etc. 

The  external  capsule  is  a  thin,  longitudinal  strand  of  white 
matter  which  lies  between  the  lenticular  nucleus  and  the  island 
of  Reil.  It  consists  of  fibers  whose  course  has  not  been  deter- 
mined, but  they  are  believed  to  be  association-fibers. 


BLOOD-SUPPLY    OF    THE    CRANIAL   CONTENTS  IO9 

BLOOD-SUPPLY  OF   THE   CRANIAL   CONTENTS 

Blood  enters  the  cranial  cavity  principally  by  means  of  two  ver- 
tebral and  two  internal  carotid  arteries.  The  two  vertebral  ar- 
teries enter  through  the  foramen  magnum,  and  pass  forward  and 
upward  in  front  of  the  medulla  to  unite  and  form  the  basilar 
artery  at  the  lower  part  of  the  pons  Varolii.  The  vertebral  ar- 
teries give  off  the  posterior  inferior  cerebellar  arteries,  w^hich  wind 
backward  around  the  upper  part  of  the  medulla  to  the  under 
surface  of  the  cerebellum.  These  vessels  anastomose  with  the 
anterior  inferior  cerebellar  and  the  superior  cerebellar  arteries, 
which  are  branches  of  the  basilar  artery;  branches  from  the  pos- 
terior inferior  cerebellar  go  to  the  choroid  plexus  of  the  fourth 
ventricle.  From  the  basilar  arise  transverse  branches  that 
supply  the  pons  Varolii  and  adjacent  parts  of  the  brain.  One 
branch,  the  internal  auditory,  accompanies  the  auditory  nerv^e 
into  the  internal  auditory  meatus.  Another  branch,  the  ante- 
rior inferior  cerebellar  artery,  is  distributed  to  the  anterior 
border  of  the  inferior  surface  of  the  cerebellum.  The  superior 
cerebellar  artery  arises  near  the  termination  of  the  basilar,  winds 
around  the  crura  cerebri,  and  is  distributed  to  the  upper  surface 
of  the  cerebellum.  The  posterior  cerebral  arteries  are  two 
terminal  branches  of  the  basilar.  They  wind  around  the  crura 
cerebri,  and  pass  to  the  surface  of  the  occipital  lobe  of  the 
cerebrum.  Near  their  origin  they  receive  the  posterior  commu- 
nicating arteries  from  the  internal  carotid.  Branches  of  the 
posterior  cerebral  and  of  the  posterior  communicating  arteries 
enter  the  posterior  perforated  space  and  supply  the  inner  surface 
of  the  optic  thalamus,  etc.  (Fig.  58). 

The  Internal  Carotids. — The  two  internal  carotid  arteries 
enter  the  cranial  cavity  through  the  S-shaped  canal  in  the 
petrous  portion  of  the  temporal  bone.  Perforating  the  dura  on 
the  inner  side  of  the  anterior  clinoid  process,  the  internal  carotid 
then  enters  the  inner  extremity  of  the  fissure  of  Sylvius,  where 
it  gives  off  its  cerebral  branches.  This  portion  of  the  artery 
has  the  optic  ner^^e  on  its  inner  side  and  the  third  nerv^e  externally. 
It  divides  into  the  anterior  cerebral,  the  middle  cerebral,  the 
posterior  communicating,  and  the  anterior  choroid  arteries 
(Fig.  58). 


no 


MANUAL   OF  NERVOUS   DISEASES 


The  anterior  cerebral  artery  passes  forward  in  the  great 
longitudinal  fissure  between  the  two  anterior  lobes  of  the  brain, 
being  connected,  soon  after  its  origin,  with  the  vessels  of  the 
opposite  side  by  a  short  anastomosing  trunk — the  anterior 
communicating.     The  two  anterior  cerebral  arteries,  lying  side 


Opfic  chlasmcL  Olfactory  hulb 


^nt.cemmunicafi. 
ariery 


Pitu'ifartf 


Middle 
Cerebral 


Z^nerve 

Int.  carotid  artery 


/Int.  infer/or 
Cerebel/ar  art- 


VertebrczL  arf. 


Sjoinal  cord 


hst.  in  f.  Cerebellar  art- 


Fig.  58. — The  arteries  of  the  base  of  the  brain. 


by  side,  curve  around  the  anterior  part  of  the  corpus  callosum, 
and  run  along  its  upper  surface  to  its  posterior  part,  where  they 
terminate  by  anastomosing  with  the  posterior  cerebral  arteries. 
These  vessels  give  off  branches  that  pierce  the  anterior  perforated 
space  and  supply  the  caudate  nucleus.  Branches  are  also  given 
off  which  supply  the  two  inferior  frontal  convolutions,   the 


BLOOD-SUPPLY    OF    THE    CRANIAL   CONTENTS 


III 


corpus  callosum,  the  inner  surface  of  the  first  frontal  and  the 
upper  part  of  the  ascending  frontal  convolutions,  and  the  medial 
aspect  of  the  quadrate  lobe  (Fig.  59). 

The  middle  cerebral  artery  is  the  largest  branch  of  the  internal 
carotid.  It  passes  outward  along  the  fissure  of  Sylvius  over  the 
island  of  Reil,  and  divides  into  terminal  branches.  It  gives  off 
many  short  branches  which  pierce  the  anterior  perforated  space 
and  supply  the  caudate  nucleus,  the  lenticular  nucleus,  the 


^nf.  cerebral  ar/ieri/ 


Great  cerebraJveia 


ce.rebel/ar 
•tcrif 


^tlt  Cerebra.1  artery 

/^ntcommunicafim 
PosKcommumcafin^ 

^4nt  Inferior  cerebelJar 


Post,  inferior  cerebellar  artery 


Fig.  59. — The  arteries  of  the  mesial  surface  of  the  cerebrum  and  of  the 
surface  of  the  cerebellum. 


internal  capsule,  and  part  of  the  optic  thalamus.  One  of  these 
arteries,  distributed  to  the  lenticular  nucleus,  is  of  a  larger  size 
than  the  others.  It  is  of  special  importance  as  being  the  artery 
in  the  brain  that  is  most  frequently  ruptured.  Charcot  has 
termed  it  ''the  artery  of  cerebral  hemorrhage"  (Fig.  60).  It  also 
sends  branches  to  the  third  ascending  frontal,  the  parietal  and 
the  temporal  lobes,  and  the  angular  gyrus  (Fig.  61). 
The  posterior  communicating  artery  arises  from  the  back  part 


112 


MANUAL   OF   NERVOUS   DISEASES 


Mid.  c 


Mid.  C. 


Fig.  60.— Showing  distribution  of  blood-vessels  to  the  internal  cap- 
sule, artery  marked  X  is  the  so-called  "artery  of  hemorrhage."  (Starr, 
after  Duret.) 


Superior  Cerebral  veirt 


Lqt  lacu/ia 

of  superioK^ 


hranch  oF 
m'iddle  ■ 
cerqbral 
arteri/ 


UraJ  lacuna  of 

sup.sagill.  sinus 


Sup&riorSa<jtttcd  Vein         Super  idr  sagittal  ■sinus 

Pig  5j  _xhe  arteries  and  veins  of  the  brain  as  seen  from  above. 


BLOOD-SUPPLY   OF   THE   CRANIAL  CONTENTS 


113 


of  the  internal  carotid,  runs  directly  backward,  and  anastomoses 
with  the  posterior  cerebral  and  branches  of  the  basilar  artery. 
The  Anterior  Choroid  Artery. — ^This  is  a  small  branch  which 
arises  from  the  back  part  of  the  internal  carotid  and  enters  the 
descending  horn  of  the  lateral  ventricle.  It  is  distributed  to  the 
choroid  plexus  and  to  structures  in  this  portion  of  the  lateral 
ventricle. 


L^l:>>Precerehral  artery. 

Intem^'^carolid  aartery. 


Fig.  62. — Diagram  of  the  arterial  circulation  at  the  base  of  the  brain: 
I,  Anteromedian  group  of  ganglion  branches;  II,  posteromedian  group; 
III,  right  and  left  anterolateral  group;  IV,  right  and  left  postlateral  group. 
The  dotted  line  shows  the  limit  of  the  ganglionic  circle.     (After  Charcot.) 


The  Circle  of  Willis. — This  is  the  designation  by  which  the  re- 
markable anastomosis  at  the  base  of  the  brain  is  familiarly  known 
(Fig.  62).  It  is  formed,  in  front,  by  the  anterior  cerebral  arteries 
and  branches  of  the  internal  carotid,  which  are  connected  by 
the  anterior  communicating;  behind,  by  the  two  posterior  cere- 
bral branches  of  the  basilar  arteries,  which  are  connected  on 
each  side  with  the  internal  carotid  by  the  posterior  communi- 
cating artery.     From  the  circle  of  Willis  three  trunks  arise  which, 


114  MANUAL   OF   NERVOUS   DISEASES 

together,  supply  each  cerebral  hemisphere.  From  the  anterior 
part  there  are  two  anterior  cerebral;  from  the  anterolateral 
part,  the  middle  cerebral;  and  from  the  posterior  part,  the  poste- 
rior cerebral.  The  principal  arteries  give  origin  to  two  very 
different  systems  of  secondary  vessels.  One  of  these  systems 
has  been  named  the  central  ganglionic  system.  The  vessels 
belonging  to  this  system  supply  the  central  ganglia  of  the  brain. 
The  other  has  been  named  the  cortical  arterial  system :  its  vessels 
ramify  in  the  pia  mater  and  supply  the  cortex  and  subjacent 
medullary  matter.  These  two  systems,  though  having  a 
common  origin,  do  not  communicate  at  any  point  of  their 
peripheral  distribution.  Between  these  two  systems  a  border- 
line of  tissue  exists  where  softening  is  especially  likely  to  occur. 

The  Central  Ganglionic  System. — All  the  vessels  belonging 
to  this  system  are  given  off  from  the  circle  of  Willis  or  from  the 
vessels  in  its  immediate  vicinity.  These  vessels  are  smaller  than 
those  of  the  cortical  system,  and  are  terminal  arteries;  that  is, 
vessels  that,  from  their  origin  to  their  termination,  neither 
supply  nor  receive  any  anastomotic  branches. 

The  Cortical  Arterial  System. — The  vessels  forming  this  system 
are  branches  of  the  anterior,  middle,  and  posterior  cerebral 
arteries.  They  divide  and  ramify  in  the  substance  of  the  pia 
mater,  and  then  give  off  terminal  arteries,  some  of  which  are 
short  and  others  long.  Each  of  these  terminal  branches  supplies 
a  definite  area  of  cerebral  substance. 

FUNCTIONS  OF  THE  WHITE  SUBSTANCE  OF  THE 

CEREBRUM 

Four  distinct  sets  of  fiber  tracts  may  be  distinguished  in  the 
brain:  tangential,  commissural,  associative,  and  projection. 

The  tangential  tracts  consist  of  numerous  short  fibers,  partic- 
ularly well  marked  in  the  cortex,  and  connecting  cells  situated 
within  a  short  distance  of  one  another. 

The  Commissural  Tracts.— T\its&  are  the  pathw^ays  that 
connect  similarly  situated  areas  of  the  two  cerebral  hemispheres 
with  each  other.  The  corpus  callosum  is  the  best  developed  of 
any  of  these  pathways.     (See  Figs.  53  and  54.) 


FUNCTIONS    OF    WHITE    SUBSTANCE    OF    CEREBRUM      II5 

The  associative  tracts  are  those  that  interconnect  various 
regions  of  the  brain  with  each  other.     (See  Fig.  55.) 

Projection  Tracts. — These  are  the  tracts  that  connect  the 
cerebral  cortex  with  the  parts  below.     (See  Fig.  56.) 


Fig.  63. — Diagram  showing  relative  position  of  chief  tract  in  internal 
capsule:  F.T.,  Frontothalamic;  F.P.,  frontopontine;  C.B.,  corticobulbar; 
C.S.,  corticospinal;  S.,  tegmental  sensory;  T.O.P.,  temporo-occipitopontine; 
O.K.,  optic  radiation;  N.L.,  lenticular  nucleus;  N.C.,  caudate  nucleus; 
T.H.O.,  optic  thalamus. 


The  region  between  the  optic  thalamus  and  the  caudate 
nucleus  internally,  and  the  lenticular  nucleus  externally,  is 
called  the  internal  capsule.     (See  Fig.  57.) 

The  projection  tracts  from  the  frontal  lobe  occupy  the  ante- 
rior limb  of  the  internal  capsule.  The  projection  tracts  from  the 
third  frontal  and  lower  precentral  convolution  occupy  the  knee  of 
the  internal   capsule.     Posterior  to   these  are  the  projection 


Il6  MANUAL   OF  NERVOUS   DISEASES 

tracts  from  the  middle  portion  of  the  precentral  convolution, 
and  posterior  to  these  are  the  projection  tracts  from  the  superior 
portion  of  the  precentral  convolution.  The  posterior  third  of 
the  posterior  limb  of  the  internal  capsule  is  occupied  by  fibers 
that  have  ascended  from  the  spinal  cord,  medulla,  lenticular 
nucleus,  and  optic  thalmus,  to  end  around  cells  in  the  parietal 
and  temporal  lobes. 

The  knee  and  the  anterior  two-thirds  of  the  posterior  limb  of 
the  internal  capsule  are  occupied  by  fibers  that  transmit  impulses 
which  result  in  voluntary  motion.  The  posterior  third  of  the 
posterior  limb  is  occupied  by  fibers  that  transmit  impulses  which 
bring  about  sensory  impressions  (Fig.  63). 

In  the  knee  and  posterior  limb  of  the  internal  capsule,  from 
before  backward,  are  placed,  in  the  order  in  which  they  are 
named,  the  pathways  of  the  stimuli  which  bring  about  move- 
ments of  the  tongue,  lips,  face,  eyes,  hands,  arms,  legs,  and  trunk. 
In  the  posterior  third  are  the  pathways  of  the  stimuli  which  are 
reflected  on  consciousness  as  sensation. 

FUNCTION  OF  THE  CEREBRAL  CORTEX 

In  the  cells  of  the  first  and  frontal  lobes  are  centered  the 
memories,  which  may  be  either  inherited  or  acquired,  and  which 
exercise  supervision  over  the  moral  character  and  intellectual 
abilities  of  the  individual.  The  third  frontal  convolution  on  the 
left  side,  in  right-handed  individuals,  and  on  the  right  side,  in 
left-handed  individuals,  is  the  motor  speech  center.  Here  are 
stored  the  memories  which,  when  called  into  activity,  result  in 
the  sounds  w^hich  we  understand  as  language.  In  the  posterior 
part  of  the  frontal  lobe,  the  precentral  convolution,  and  most 
likely  extending  for  a  short  distance  posterior  to  the  fissure  of 
Rolando  in  the  postcentral  convolution,  are  situated  the  centers 
which  control  the  voluntary  movements  of  the  body.  Those 
in  the  left  cerebral  cortex  supervise  the  motor  activities  of  the 
right  side,  and  those  in  the  right  cerebral  cortex  govern  the 
motor  activities  of  the  left  side.  The  centers  for  the  voluntary 
movements  of  the  eyes  and  face  are  situated  lowest  down  and 
somewhat  anteriorly  in  the  precentral  convolution;  those  for  the 


f^RONTAL 


o 

O 


TfMPo/j^L 


LOBt 


Fig.  63  (Z. — Median    view    of    the   cerebral   cortex   showing   location   of 
important  centers  (diagrammatic). 


LOB3 


TEMPORAL      LOBf 


Fig.  63  b. — Lateral     view    of    the    cerebrum    showing    the    location   of 
important  centers  (diagrammatic). 


FUNCTION    OF    THE    CEREBRAL   CORTEX  II7 

movements  of  the  fingers,  hands,  and  arms  being  somewhat 
higher  and  farther  back.  Above  these  are  the  centers  for  the 
movements  of  the  trunk  and  legs. 

In  the  postcentral  convolution  and  in  the  anterior  part  of  the 
parietal  lobes  the  stimuli  that  are  reflected  upon  consciousness 
as  sensation  are  received. 

In  the  angular  gyrus  are  associated  various  impressions  that 
result  in  the  stereognostic  sense.  In  the  cuneus  and  on  the 
lateral  aspect  of  the  occipital  lobe  are  the  centers  of  sight,  and 
in  these  centers  are  stored  the  memories  that  enable  us  to  rec- 
ognize the  things  that  are  seen.  In  the  anterior  part  of  the 
lateral  aspect  of  the  occipital  lobe  is  the  reading  center.  In  the 
superior  temporal  convolution  are  stored  the  memories  of 
sounds  heard — the  auditory  sense,  which  enables  an  individual 
to  understand  spoken  language.  In  the  internal  aspect  of  the 
temporal  lobe,  in  the  uncus  and  hippocampal  convolution,  are 
the  cells  in  W'hich  are  stored  the  memories  of  odors — the  olfactory 
sense — and  those  of  taste — the  gustatory  sense. 

The  Functions  of  the  Basilar  Ganglia. — The  corpora  striata 
and  the  optic  thalami  are  believed  to  be  intermediate  stations 
for  the  conduction  of  sensation.  The  optic  thalami  also  receive 
filaments  from  the  optic  tracts,  and  are  intermediate  stations 
of  vision  and  of  reflex  activity. 

The  functions  of  about  one-third  of  the  cortex  of  the  brain 
are  understood,  and  the  remainder,  or  two-thirds,  is  believed 
to  be  concerned  with  associative  interactivity. 

The  Functions  of  the  Hypophysis  Cerebri. — ^The  anterior  lobe 
secretes  a  substance  that  enters  the  blood  and  promotes  skeletal 
growth.  The  secretion  of  the  posterior  lobe  influences  the 
processes  of  tissue  metabolism  and  the  activity  of  the  renal  and 
vascular  systems. 

The  Course  of  a  Motor  and  a  Sensory  Impulse  From  the 
Point  of  its  Origin  to  the  Area  in  which  it  Produces  its  Effect. — ^A 
inotor  impulse  originating  in  the  precentral  convolution  descends 
through  the  projection  pathways  into  the  internal  capsule,  where 
it  passes  through  an  area  somewhere  between  the  knee  and  the 
posterior  third  of  the  posterior  limb.  It  then  crosses  the  opposite 
side,  to  end  aro-ond  the  nucleus  of  the  third  or  fourth  nerve,  or 


Il8  MANUAL   OF   NERVOUS   DISEASES 

it  may  enter  the  crura,  where  it  will  pass  through  an  area 
occupying  the  middle  three-fifths  of  the  anterior  portion  of  this 
structure.  It  may  then  cross  the  opposite  side,  to  end  around 
the  motor  nucleus  of  the  fifth  nerve,  or  it  may  enter  the  pons, 
where  it  will  pass  through  an  area  situated  anteriorly.  It  may 
next  cross  the  opposite  side,  and  end  around  the  nucleus  of  the 
sixth  or  seventh  nerve,  or  it  may  descend  into  the  pyramids  of 
the  medulla,  and  at  this  point  cross  the  opposite  side,  to  stimulate 
the  nucleus  of  the  ninth,  tenth,  eleventh,  or  twelfth  nerve. 
Instead,  however,  it  may  continue  downward  through  the  pyra- 
mids of  the  medulla  to  the  lower  portion  of  the  medulla,  w^here 
90  per  cent,  of  the  fibers  cross  the  opposite  side  and  make  up 
the  crossed  pyramidal  tracts,  10  per  cent,  descending  on  the 
same  side  as  the  direct  pyramidal  tracts  of  the  spinal  cord.  As 
the  impulse  descends  through  the  crossed  pyramidal  tracts,  it 
will  stimulate  to  activity  cells  in  the  anterior  horns  of  the  same 
side  of  the  cord  as  that  on  which  it  descends.  If  it  descends  in 
the  direct  pyramidal  tract,  before  it  stimulates  cells  in  the  ante- 
rior horn  it  will  cross  in  the  anterior  or  white  commissure  of  the 
spinal  cord,  to  stimulate  cells  in  the  anterior  horns  of  the  opposite 
side  of  the  cord.  As  the  result  of  the  stimulation  of  the  cells  of 
the  nuclei  of  the  cranial  nerve,  or  of  cells  in  the  anterior  horn  of 
the  spinal  cord,  new  impulses  arise  which  are  transmitted  through 
the  cranial  nerves  or  spinal  nerves,  to  stimulate  the  muscle- 
fibers  to  activity  and  result  in  the  execution  of  purposive  and 
voluntary  actions   (Figs.   64  and  65;   also   see  Figs.   33   and 

67). 
The  Course  of  a  Sensory  Impulse. — The  stimulus,  originating 

in  the  periphery,  affecting  the  termination  of  a  sensory  nerve 

travels  upward  through  the  ganglionic  cells  which  are  situated 

on  all  sensory  nerves;  it  then  enters  the  spinal  cord  through  the 

posterior  roots  or  the  medulla  or  pons,  through  the  superficial 

origin  of  the  cranial  nerves.     If  the  sensory  impulse  enters  the 

medulla  or  the  pons,  it  stimulates  to  activity  cells  situated 

beneath  the  floor  of  the  fourth  ventricle.     From  these  cells  new 

fibers  arise  which  transmit  the  impulse.     These  fibers  ascend 

on  the  same  or  on  the  opposite  side  through  the  fillet,  to  end 

around  the  cells  in  the  lenticular  nucleus  or  optic  thalami. 


FUNCTION    OF    THE    CEREBRAL    CORTEX 


119 


Some  fibers  ascend  through  the  posterior  portion  of  the  posterior 
limb  of  the  internal  capsule,  to  end  around  the  cells  in  the 


Horizontal  section 
OF  THfief) 
CAPSULE. 


Ve>-ti'cal  Seci'on  of 
intn.rnoJ  capsule 


Horizontal  sec  f tan 
efCrua 


Motor  Decc/ssafion 
in  Medulla. 


horizonlal  section 
of  the  spinaJ  cord 


Oirect  nyramidal 
tract 


Crossed  pyramidal 
tract.     '^' 


Anterior  root  of 
Spinal  nerve ^ 


•  Indirect  Paihway 
Central  (upper)  Neurone 
Peripheral  (lower)  Neurone 


inferior  root  of 
'Spinal  nerve 


Figs.  64  and  65. — Motor  pathway. 


parietal  lobe.  A  sensory  impulse  may  also  be  conducted  by 
other  fibers  arising  in  cells  beneath  the  floor  of  the  fourth  ven- 
tricle, which  may  or  may  not  cross  the  midline,  and  which  may 


I20 


MANUAL   OF  NERVOUS  DISEASES 


end  around  cells  in  the  pons,  the  medulla,  the  crura,  or  the  vermis 
of  the  cerebellum  (Fig.  66;  also  see  Fig.  33  and  Fig.  67). 
If  the  impulse  is  transmitted  by  one  of  the  spinal  nerves, 


Cortex. 


Antero-Lateral 
ascending  Tract 


Dir&cf  cerebellt 
CoJuntn 


Optic  Thalcunus. 


HorizonfccL  Section 
of  Crus. 


a         Sensory  Crannxl 
N&rves . 


HortT-onfaL  Section 
of  Spinal  cord. 


Sensory  branch  to  , 
motor  cell  in  ant.  tit 


orn. 


Ga^flicn^-^ 

Dendrites.' 

Fig.  66. — Sensory  pathways. 


Ganglion  of  post' 
(sensory)  roof. 


it  enters  the  spinal  cord  through  the  posterior  roots,  where  it  may 
pursue  one  of  the  several  pathways.     (See  Fig.  33.) 

Muscle  Sense.— A  muscle  sensation  is  transmitted  by  fibers 


FUNCTION    OF    THE    CEREBRAL    CORTEX  121 

that  ascend  a  short  distance  in  Lissauer's  column  and  then 
enter  the  column  of  Goll  or  Burdach.  Most  of  these  fibers  are 
on  the  same  side  and  a  few  are  on  the  opposite  side.  The  fibers 
ascend  and  end  around  cells  in  the  nucleus  of  Goll  or  Burdach. 
From  these  cells  fibers  arise  that  cross  to  the  opposite  side,  and 
ascend  in  the  fillet  through  the  medulla,  pons,  or  crura.  Some 
fibers  end  around  cells  in  the  lenticular  nucleus  or  optic  thalami, 
and  from  these  cells  new  fibers  arise  which  enter  the  posterior 
part  of  the  internal  capsule,  to  terminate  around  cells  in  the 
parietal  lobe.  Other  fibers  originating  in  cells  in  the  nucleus  of 
Goll  and  Burdach  may  continue  to  ascend  through  the  medulla, 
pons,  and  crura,  to  the  posterior  part  of  the  internal  capsule,  to 
end  around  cells  in  the  parietal  lobe.  Still  other  fibers  (arciform 
fibers),  originating  in  cells  situated  in  the  nucleus  of  Goll  or  Bur- 
dach, most  of  which  cross  the  midline,  cross  through  the  retic- 
ular formation  and  enter  the  inferior  peduncle  of  the  cerebellum, 
to  end  around  cells  in  the  vermis. 

Pain  and  Temperature  Sense.— The  stimuli  which  originate 
in  the  periphery  ascend  through  the  sensory  nerv^es,  the  ganglion 
on  the  posterior  roots;  they  ascend  through  the  posterior  roots 
to  enter  the  spinal  cord.  From  here  they  ascend  for  a  short 
distance  in  Lissauer's  column,  after  which  they  enter  the  pos- 
terior horns  to  stimulate  cells  in  the  anterior  part  of  the  poste- 
rior horns.  From  these  cells  fibers  arise  that  ascend  and  cross 
through  the  gray  commissure  to  enter  the  anterolateral  column 
of  the  opposite  side.  The  impulse  then  ascends  through  this 
column,  which  becomes  deflected  dorsalward  and  centrally  upon 
entering  the  medulla,  where  it  ascends  through  the  reticular 
formation,  becoming  a  part  of  the  lemniscus  of  the  medulla  and 
pons  and  entering  the  tegmentum  of  the  crura.  Some  of  these 
fibers  terminate  around  cells  in  the  optic  thalami  and  lenticular 
nucleus,  the  greater  number  of  them  ascending  through  the 
posterior  limb  of  the  internal  capsule  to  enter  the  parietal  lobe, 
where  they  end  around  cells  in  the  cortex  of  the  lobe. 

Tactile  Sense.— This  form  of  sensation  is  transmitted  through 
two  pathways:  it  partly  follows  the  pathway  that  conducts 
muscle  sensations,  and  in  part  follows  the  pathway  that  con- 
ducts pain  and  temperature  sense. 


122 


MANUAL   OF   NERVOUS   DISEASES 


fSensoty  Jlrea 


Mofor/lrecL 


^^-Tail  of  Caudate  Nucleus 


Decu^saTfon 

Crossed  l^namida 

Motor  Root 
Direct  f^romidd 


Antero-latera 
Ground  Bundle 


Root  Gijnglion 
Fig.  67. — Combined  motor  and  sensory  pathways. 


ANATOMY    AND   PHYSIOLOGY    OF    THE    CEANIAL   NERVES    1 23 

Equilibrium. — The  principal  pathway  for  this  function  of  the 
nervous  system  is  the  direct  cerebellar  tract.  Stimuli  which 
assists  in  maintaining  this  function  originate  in  the  periphery, 
ascend  through  the  peripheral  nerves,  through  the  ganglia  on 
the  posterior  roots,  enter  the  cord  through  the*  posterior  roots, 
then  ascend  a  short  distance  in  Lissauer's  marginal  zone,  then 
enter  the  posterior  horns  where  they  stimulate  to  activity 
cells  in  the  column  of  Clark.  These  stimuli  are  then  trans- 
mitted through  fibers  which  arise  from  the  cells  in  the  column 
of  Clark  and  w^hich  cross  through  the  gray  and  white  matter 
of  the  posterolateral  portion  of  the  cord,  then  turn  upward 
and  form  the  direct  cerebellar  tract;  this  column  ascends  in 
the  posterolateral  margin  of  the  cord;  in  the  medulla  it  is  de- 
flected slightly  forward,  forms  an  important  portion  of  the 
inferior  cerebellar  peduncle,  its  fibers  entering  the  cerebellum 
and  terminating  around  cells  in  the  vermis. 

Impulses  w^hich  assist  in  maintaining  equilibrium  also  orig- 
inate in  the  spiral  ganglia  and  are  transmitted  through  the 
vestibular  portion  of  the  eighth  nerve  to  the  medulla;  from 
here,  through  the  interposition  of  other  neurons,  they  are  trans- 
mitted to  the  vermis  of  the  cerebellum. 

A  careful  study  of  Figs.  33  and  37,  showing  the  pathways 
of  these  various  forms  of  sensation,  will  disclose  the  rela- 
tive spatial  relation  of  these  pathw^ays  to  one  another,  to  the 
cellular  constituents  of  the  spinal  cord,  to  the  nuclei  of  the 
cranial  nerv- es,  and  to  the  tracts  of  the  medulla,  pons,  and  crura. 

ANATOMY  AND   PHYSIOLOGY  OF  THE   CRANIAL 

NERVES 

The  First  or  Olfactory  ^erve. — This  nerve  receives  stimuli  at 
its  special  endings  in  the  Schneiderian  mucous  membrane  of  the 
nose.  The  fibers  of  this  nerve  enter  the  cranial  cavity  through 
the  cribriform  plate  of  the  ethmoid  bone,  and  there  enter  the 
cells  of  the  olfactory  bulbs.  The  axons  of  these  cells  pass  through 
the  olfactory  tracts.  The  impulse  then  enters  either  the  medial 
or  the  lateral  root,  the  medial  root  going  in  part  to  the  callosal 
and  subcallosal  gyrus,  and  in  part  to  the  area  of  Broca.    The 


124 


MANUAL  OF  NERVOUS  DISEASES 


Fig.  68. — Nuclei  of  origin  of  motor  and  primary  terminal  sensory  nuclei 
of  cerebral  nerves  (Held),  schematically  represented  in  a  supposedly 
transparent  brain  stem  viewed  from  behind:  4,  Nucleus  of  the  third 
nerve  (n.  oculomotorii) ;  5,  nucleus  of  the  fourth  nerve  (n.  trochlearis) ; 
6,  the  fourth  nerve;  7,  the  descending  (motor)  root  of  the  fifth  nerve;  8, 
the  principal  motor  nucleus  of  the  fifth  nerve;  9,  the  semilunar  ganglion 
(g.  Gasseri);  26,  the  ascending  (sensory)  root  of  the  fifth  nerve;  14,  nu- 
cleus of  the  sixth  cranial  nerve;  15,  nucleus  of  facial  (seventh)  nerve;  16, 
the  facial  nerve;  34,  33,  nucleus  of  the  vestibular  branch  of  the  eighth 
cranial  nerve;  32,  ventral  nucleus  of  the  cochlear  branch  of  the  eighth 
nerve;  27,  dorsal  nucleus  of  the  cochlear  branch  of  the  eighth  nerve;  19, 
29,  the  glossopharyngeal  nerve;  18,  28,  the  vagus  nerves  20,  motor  nuclei 
of  vagus  and  glossopharyngeal  (nucleus  ambiguus  and  nucleus  dorsalis); 
23,  24,  nucleus  of  the  alae  cinereae,  the  solitary  bundle  and  its  nucleus;  17, 
the  eleventh  or  spinal  accessory  nerve;  22,  nucleus  of  the  spinal  accessory; 
21,  nucleus  of  the  hypoglossal  nerve.  (From  Spalteholz,  "Human  Anat- 
omy.") 


ANATOMY    AND    PHYSIOLOGY    OF    THE    CRANIAL    NERVES    1 25 

lateral  root  enters  the  anterior  perforated  space,  and  terminates 
finally  in  the  uncinate  gyrus  of  the  temporal  lobe.  A  few  of  the 
fibers  of  the  olfactory  tract  terminate  in  the  anterior  end  of  the 
optic  thalamus,  whereas  others  pass  through  the  anterior  white 
commissure.  The  function  of  this  nerve  is  to  receive,  in  special- 
ized endings  and  transmit,  stimuli  that  result  in  the  sense  of 
smell. 

The  Second  or  Optic  Nerve. — The  second  or  optic  nerve  is 
the  nerve  that  receives  and  conducts  stimuli  resulting  in  sight. 
The  stimuli  afTect  the  specialized  terminations  of  these  nerves 
in  the  fundus  of  the  eyes.  All  stimuli  originating  to  the  right  of 
the  midline  affect  the  left  halves  of  the  fundi  of  the  two  eyes; 
those  which  originate  to  the  left  of  the  midline  affect  the  right 
halves  of  the  fundi  of  the  two  eyes.  These  stimuli  are  conducted 
backward  through  the  optic  nerves.  Those  stimuli  which  have 
arisen  in  the  right  halves  are  conducted  backward  through  the 
right  optic  tract,  whereas  those  which  aft'ect  the  left  halves  are 
conducted  backward  through  the  left  optic  tract.  The  optic 
tracts  send  fibers  into  the  external  geniculate  body  and  the  optic 
thalamus  of  the  same  side.  In  the  optic  thalamus  new  fibers 
arise — the  optic  radiations — which  appear  posterior  to  the 
internal  capsule  and  end  in  the  cuneus  of  the  occipital  lobe. 

All  objects  to  the  left  of  the  midline  are  seen  as  the  result 
of  stimulation  of  the  right  occipital  cortex,  and  that  all  objects 
to  the  right  of  the  midline  are  seen  as  the  result  of  stimulation 
of  the  left  occipital  cortex. 

The  Third  or  Oculomotor  Nerve. — This  is  the  motor  ner\'e  of 
all  the  external  and  internal  muscles  of  the  eye  except  the 
sphincter  palpebra,  the  external  rectus,  and  the  superior 
oblique.  Its  nucleus  of  origin  is  in  the  gray  matter  around  the 
aqueduct  of  Sylvius,  in  the  lower  portion  of  the  crura,  and 
consists  of  a  long  column  of  cells  (Fig.  69).  The  ner^^es,  which 
most  likely  contain  filaments  from  both  nuclei,  pierce  the 
structures  of  the  crura  and  appear  one  on  each  side  of  the  mid- 
line, on  the  inner  side  of  the  cerebral  peduncles,  immediately 
above  the  pons.  The  nerve  pursues  an  anterior  course,  and 
pierces  the  dura  mater  in  front  of  and  external  to  the  posterior 
clinoid  process.     It  passes  along  the  outer  wall  of  the  cavernous 


126 


MANUAL   OF   NERVOUS   DISEASES 


sinus  above  the  other  orbital  nerves,  receiving  in  its  course 
filaments  from  the  cavernous  plexus  of  the  sympathetic  and 
from  the  ophthalmic  division  of  the  fifth  nerve.  It  enters  the 
orbit  through  the  sphenoidal  fissure.     It  divides  into  numerous 


Tetriporo.-Ocdpiro 
Pontine  Tract' 

Trunk-- 
Leg— 
Arm- 
Face' 
Fronto  Pontine  Tract 


^^■Superior  Quad, 
^' Optic  Acoustic  Ref/ex  Path 
'Ac^ueduct  of3ylvius 
Nucleus  of  Third (ni)Net-i^e 
Middle  Lemniscus 
Red  Nucleus 

\^Subsf.  Nigra. 

-  Caudate  Cerebellar 
iroct 


Roof  of m 


Fig.  69. — Diagram  showing  the  deep  and  superficial  origin  of  the  third 
nerves,  the  relation  of  these  nerves  to  the  crura  cerebri,  and  their  connection 
with  the  cerebral  cortex. 


branches,  supplying  the  superior  rectus,  inferior  rectus,  levator 
palpebrae,  internal  rectus,  and  inferior  oblique,  sending  a  branch 
also  to  the  lenticular  ganglion,  and  from  this,  through  a  short 
ciliary  nerve,  to  the  ciliary  muscle  and  sphincter  of  the 
pupil. 


ANATOMY  AND  PHYSIOLOGY  OF  THE  CRANIAL  NERVES  1 27 

The  Fourth  or  Trochlear  Nerve  (Fig.  70). — The  nucleus  of 
origifi  of  this  nerve  is  immediately  below  that  of  the  third  nerve. 
Its  fibers  take  a  backward  course  and  cross  in  the  midline  in  the 
valve  of  Vieussens.  It  appears  to  the  outer  side  of  the  cerebral 
peduncles,  between  the  cerebrum  and  cerebellum,  and  then 
pursues  an  anterior  course  with  the  third  nerve,  to  enter  the 
orbit  through  the  sphenoidal  fissure  to  supply  the  superior 
oblique  muscle. 

The  fifth  or  trifacial  nerve  is  the  largest  of  the  cranial  nerves 
(Fig.  71).    It  resembles  the  spinal  nerve  in  that  it  arises  by  two 


Decussation  ofJV 
Nucleus  ofIVJ\len/e  !^_  _ 

Fasclcu/us  Longiti/dinah's- 
MediaJis 

Bundle  from  RedUc/cleui'  ' 
To  the  LaTera./  roni cuius 


Descending  Roof  of  V 
Trochlear  Nen/e  Rool(lV) 

Brachium  ConjuncfivcL 
■Lateral  Lemniscus 

f\/tiddle  lemniscus 


^^^h'Pons 


Fig.  70. — Diagram  sho-u-ing  the  deep  and  superficial  origin  of  the  fourth 
nerv^es,  the  relation  of  these  nerv^es  to  the  crura  cerebri,  and  their  connection 
with  the  cerebral  cortex. 


roots  and  is  a  mixed  nerv- e.  Its  motor  root  arises  from  cells  lying 
below  the  floor  of  the  fourth  ventricle,  near  the  lateral  angle. 
Its  sensory  root  has  its  cells  of  origin  in  the  Gasserian  ganglion. 
The  motor  root  pierces  the  structures  of  the  pons  and  appears 
at  the  side  near  its  upper  margin.  The  sensory  root  enters  the 
pons  at  this  point,  dividing  into  ascending  and  descending  fibers 
that  end  around  cells  beneath  the  floor  of  the  fourth  ventricle, 
extending  upward  as  far  as  the  crura  and  downward  as  far  .as 
the  second  or  third  cervical  segment  of  the  spinal  cord.     The 


128 


MANUAL   OF   NERVOUS   DISEASES 


two  roots  of  the  fifth  nerve  pass  forward  through  an  oval  opening 
in  the  dura  mater  at  the  superior  border  of  the  petrous  portion 
of  the  temporal  bone,  above  the  internal  auditory  meatus. 
They  then  pursue  a  course  forward  to  the  apex  of  the  petrous 
portion  of  the  temporal  bone.  Here  is  situated  the  Gasserian 
ganglion,  under  which  the  motor  root  passes  without  entering 


Roofs  of  V' 

Mi'c/d/e  Lemniscus  -- 


Ventral  Cerebellar  Pctfh  of 
Lo-feraJ  Funiculus  (From 
Gowers  Iract) 

Bra  chium  Copjuncfiva 
Sensory  Nuckus\     /•■tr 
'- Motor  Nucleus  r^^ 
-Nucleus  of  Lai  MedivS 
Fas  C.Long.  Medialis 

Y. 

Gowers  Tract 
■Super/or  Olive 


Longitudinal  Tracts  .^^c^ 


~"  Pontile  tJuclei 
'Pontile  Fibers 


Fig.  71. — Diagram  showing  schematically  the  connection  of  the  fifth  nerve 
with  the  cerebral  cortex  and  the  relationship  of  the  nuclei  of  this  nerve  to  the 
structures  of  the  pons. 


into  it.  The  Gasserian  ganglion  is  covered  by  the  dura  mater, 
and  receives  branches  from  the  carotid  plexus  of  the  sym- 
pathetic nerve.  It  gives  off  the  following  branches:  The 
ophthalmic^  a  short  branch,  which  passes  forward  along  the  outer 
wall  of  the  cavernous  sinus,  entering  the  orbit  through  the  sphe- 
noidal fissure  (Fig.  72).     The  superior  maxillary,  which  passes 


ANATOMY    AND    PHYSIOLOGY    OF    THE    CRANIAL   NERVES    1 29 

fon\^ard,  emerges  from  the  cranial  cavity  through  the  foramen 
rotundum,  and  then  crosses  the  sphenomaxillary  fossa,  entering 
the  infra-orbital  canal  in  the  floor  of  the  orbit  and  appearing  upon 
the  face  at  the  infra-orbital  foramen.  The  inferior  maxillary 
nerve,  which  consists  of  two  portions — a  large  sensory  portion, 
being  the  third  branch  of  the  Gasserian  ganglion,  and  a  small 
portion,  which  is  the  motor  portion  of  the  fifth  nerve  and  which 
has  passed  beneath  the  ganglion.    These  two  portions  emerge 


Facia.1  nerve 


TriqemmaJ      Gasserjcui  Ophthalmic  nerve 
orS'J'n.erve     ganglion        /  .'■^^y'ln,.. 


Suprvaxil/ary 
nerve 

OphemfpaJat. 
"  ganglion 

^up. alveolar 
nerves 


Glossopharyngeal  nerve 
Cfiorda.  fympofii  nerve 
ln-f.ma>.'iilary  nerve 


Submcm'illary  ganglion , 

Lingual  nerve/      j^f  'alveolaTZ^ 

Fig.  72. — The  trigeminal  nerve  and  its  communications  ^^-ith  the  facial  and 
glossopharyngeal  nerves.     (After  Sobotta.) 


from  the  cranial  cavity  through  the  foramen  ovale,  where  they 
fuse  with  each  other. 

This  nerv^e  supplies  sensation  to  the  anterior  part  of  the  head, 
the  face,  the  orbit,  the  structures  within  the  orbit,  the  nose,  the 
mouth,  and  perhaps  the  upper  portion  of  the  neck.  Its  motor 
portion  is  distributed  to  the  muscles  of  mastication. 

The  sixth  or  abducent  nerve  supplies  the  external  rectus 
muscle  of  the  eye.*  Its  nucleus  of  origin  is  situated  beneath  the 
floor  of  the  fourth  ventricle,  in  front  of  the  acoustic  striae.     Its 


I30 


MANUAL   OF   NERVOUS   DISEASES 


fibers  pierce  the  structures  of  the  medulla  and  appear  beneath 
the  pons  near  the  midline.  The  nerve  runs  almost  directly 
forward,  crosses  the  pons,  lying  to  the  outer  side  of  the  internal 
carotid  artery,  and  enters  the  orbit  through  the  sphenoidal 


.    Dandle  from  Dieterjs.^ 
Nucleus  to  Lateral  Funiculus 


GowersTract  and  7?i 
fo  Lateral  Funiculi/, 
from  the  Red  Nude 


Corpus  Trape^oideum  ~- 
FibrcLe  Pontis  ■Super ficiajes^ 


Boot  of  VI 


l^edian  Desc.  Pontile  Path 


Rest i form  Body 

Sup-Nucleus  of  VIII 

-Nucleus  of.VI 
Spina.1  Tract  of  V 

-Nucleus  of  VII 

Hootof  VII 
Sup.  Olive 

~~~-M/dd/e  Lemniscus 

^_  jv.-  Fasciculi  Long  I  tudinahs 
(Pyramidules) 

Root  of  VI 


Fig.  73. — Transverse  section  of  the  medulla  at  the  level  of  the  sixth  and 
seventh  nerves,  showing  schematically  the  connection  of  the  nuclei  of  these 
nerves  with  the  cerebral  cortex  and  their  relation  to  each  other  and  to  the 
structures  of  the  upper  medulla. 


fissure.     It  pursues  the  longest  intracranial  course  of  any  of  the 
cranial  nerves  (Fig.  73). 

The  seventh  or  facial  nerve  is  distributed  to  the  muscles 
of    expression,   to   the   platysma,   buccinator,   posterior  belly 


ANATOMY   AND   PHYSIOLOGY    OF    THE    CRANIAL   NERVES    13I 

of  the  digastric,  stylohyoid  muscles,  etc.  Through  its  chorda 
tympani  branch  it  supplies  the  lingualis  muscle,  and  through 
its  tympanic  branch,  the  stapedius.  Its  nucleus  of  origin  is 
beneath  the  floor  of  the  fourth  ventricle,  anterior  and  external 
to  the  nucleus  of  the  sLxth  nerve.  On  leaving  the  nucleus 
the  fibers  are  at  first  directed  backward  and  inward  toward 
the  middle  line;  they  then  ascend  for  a  short  distance  behind 
the  nucleus  of  the  sixth  nervT,  close  to  the  floor  of  the  fourth 
ventricle.  They  next  bend  down  and  outward  over  the  upper 
end  of  the  nucleus  of  the  skth,  and  then  are  directed  anteriorly 
outward  and  downward,  appearing  beneath  the  lower  border  of 
the  pons  in  the  groove  between  the  olivary  and  restiform  bodies. 
The  nerve  then  passes  forw'ard  and  outward  in  close  apposition 
with  the  eighth,  and  enters  the  internal  auditory  meatus.  At 
the  bottom  of  the  meatus  the  facial  nerve  enters  the  aqueductus 
Fallopii,  and  follows  the  course  of  that  canal  through  the  petrous 
portion  of  the  temporal  bone,  emerging  at  the  stylomastoid 
foramen.  From  this  aperture  it  runs  for^vard  in  the  substance 
of  the  parotid  gland,  crosses  the  external  carotid  artery,  and 
divides  into  branches  that  are  distributed  to  the  side  of  the  head, 
face,  and  upper  part  of  the  neck,  and  supplying  the  superficial 
muscles  in  this  region. 

On  the  facial  nerve,  just  within  the  internal  auditory  meatus, 
is  the  geniculate  ganglion.  The  proximal  root,  called  the  pars 
intermedia,  or  the  ner\  e  of  Wrisberg,  enters  the  medulla  between 
the  facial  and  the  auditory  ner\^e,  and  probably  ends  around 
cells  in  the  glossopharyngeal  nucleus.  The  peripheral  root  of 
this  ganglion  joins  the  seventh,  a  portion  of  its  fibers  leaving  the 
seventh  beneath  the  floor  of  the  middle  ear  as  the  chorda  t}TQpani 
nerv^e,  to  join  the  inferior  maxillar}'  branch  of  the  fifth.  Some 
of  its  fibers  probably  serve  for  the  conduction  of  sensation  from 
a  small  cutaneous  area  and  the  external  auditory  canal  (Fig.  74) . 

The  fibers  of  the  chorda  t}Tnpani,  which  conduct  the  sense 
of  taste  from  the  anterior  two- thirds  of  the  tongue,  after  entering 
the  geniculate  ganglion,  may  transmit  stimuli  through  the  pars 
intermedia  to  the  glossophar^^ngeal  nucleus;  or  the  stimuli  may 
be  transmitted  from  the  geniculate  ganglion  through  the  great 
superficial  petrosal  nerve  to  Meckel's  ganglion,  thence  to  the 


132 


MANUAL   or  NERVOUS   DISEASES 


superior  maxillary  division  of  the  fifth  nerve,  and  through  this 
nerve  to  the  cortical  taste-centers  in  the  temporal  lobe. 


Fig.  74. — The  facial  nerve  with  its  branches  and  communications  in  the 
aqueduct  of  Fallopius:  VII.,  Facial  nerve;  P. I.,  pars  intermedia;  VIII., 
auditory  nerve;  Aq.Fal.,  aqueduct  of  Fallopius;  G.G.,  geniculate  ganglion; 
E.S.P:,  great  superficial  petrosal  nerve;  G.P.D.,  great  deep  petrosal  nerve; 
I.e.,  internal  carotid  artery;  Vid.,  vidian  nerve;  M.G.,  Meckel's  ganglion; 
Ty.PL,  tympanic  plexus;  S.D.P.,  small  deep  petrosal  nerve;  G.Ph.,  glosso- 
pharyngeal nerve;  Ty.,  tympanic  branch;  S.S.P.,  small  superficial  petrosal 
nerve;  O.G.,  otic  ganglion;  Stap,  nerve  to  stapedius;  C.T.,  chorda  tympani 
nerve;  L.,  lingual  nerve;  A.Va.,  communication  with  auricular  branch  of 
vagus;  P. A.,  posterior  auricular  nerve;  Sty.  hy.,  nerve  to  stylohyoid;  Di., 
nerve  to  digastric  (posterior  belly);  T.F.,  temporofacial  division;  C.F., 
cervicofacial  division;  T.,  temporal;  M.,  malar;  I.O.,  infra-orbital;  B.,  buccal; 
S.M.,  supramandibular;  I.M.,  inframandibular  branches. 


The  Eighth  or  Auditory  Nerve. — This  is  the  special  nerve  of 
the  sense  of  hearing,  being  distributed  exclusively  to  the  internal 
ear.  Its  cells  of  origin  are  in  the  vestibular  and  spiral  ganglia. 
These  are  situated  respectively  in  the  semicircular  canals  and  the 


ANATOMY  AND  PHYSIOLOGY  OF  THE  CRANIAL  NERVES  1 33 

internal  ear.  The  nerve,  arising  from  these  ganglia,  emerges 
from  the  petrous  portion  of  the  temporal  bone  at  the  internal 
auditor}^  meatus,  where  it  is  in  close  apposition  to,  and  remains 
connected  with,  the  seventh  nerve,  entering  the  medulla  in  the 
same  groove  with  but  behind  the  facial. 

The  medial  root,  which  is  the  vestibular  division,  passes  back- 
ward through  the  substance  of  the  medulla  and  pons,  internal 
to  the  restiform  bodies.  The  fibers  of  this  root  divide  into 
ascending  and  descending  branches.  The  ascending  branches 
end  around  cells  beneath  the  floor  of  the  fourth  ventricle,  from 
which  fibers  pass  to  the  cerebellum.  The  descending  branch  also 
ends  around  cells  beneath  the  floor  of  the  fourth  ventricle,  and 
some  of  these  fibers  can  be  traced  through  the  medulla  to  the 
spinal  cord  as  the  vestibulospiaal  tracts.  This  root  is  connected 
principally  with  the  cerebellum,  the  optic  thalami,  and  the 
nucleus  of  the  sLxth,  third,  fourth,  and  fifth  ner^-es.  It  conducts 
impulses  that  have  to  do  with  the  sense  of  equilibration. 

The  lateral  root,  or  cochlear  division,  is  the  true  nerve  of  hearing. 
It  arises  as  the  central  processes  of  the  bipolar  cells  in  the  spiral 
ganglion  of  the  cochlea.  It  passes  backward  into  the  medulla, 
on  the  outer  side  of  the  restiform  body.  Its  fibers  divide  into 
ascending  and  descending  branches.  The  ascending  branches 
end  around  cells  of  the  ventral  cochlear  nucleus.  The  descend- 
ing branches  end  around  cells  in  the  dorsal  cochlear  nucleus. 
The  further  course  of  auditor^"  impulses  is  from  the  ventral 
nucleus  through  the  trapezoid  body;  from  the  dorsal  nucleus 
through  the  acoustic  striae  and  the  trapezoid  body,  to  join  the 
superior  olives ;  through  the  lateral  fillet  of  the  same  and  opposite 
side  to  the  posterior  corpora  quadrigemina,  to  the  internal 
geniculate  body;  through  the  posterior  part  of  the  internal 
capsule,  to  the  superior  temporal  convolution. 

The  ninth  or  glossopharyngeal  is  a  mixed  ner^'e,  ha\Tng  a 
small  motor  root  in  common  with  the  tenth  nerve.  The  origin 
of  the  motor  root  is  from  the  cells  of  the  nucleus  ambiguus, 
which  is  situated  beneath  the  floor  of  the  fourth  ventricle.  The 
sensory  root  has  its  origin  in  cells  of  the  petrous  and  jugular 
ganglia.  The  motor  root  emerges  from  the  medulla  in  the  groove 
between    the   olivary    and    restiform   bodies    (Fig.    75).     The 


134 


MANUAL   OF   NERVOUS   DISEASES 


sensory  root  enters  this  groove,  dividing  into  ascending  and 
descending  branches  that  end  around  cells  beneath  the  floor  of 


Nucleus  of  lUX-^^^ 


Nucleus  ArvbiguuS 


'Descending  RoofofVOL 
Solitary  Tract 

-Resti  form  Body 

'Spinal  Tract  of  V 

IX 

X 
-Gowers'TracI 

-   Internal  Arcuate  Fibers 
Extern aJ  Arcuate  Fibers 


Olive 
Interolivare  ^Lem 


^Pyramid 


Fig.  75. — Transverse  section  of  the  medulla  at  the  level  of  the  ninth  and 
tenth  cranial  nerves,  schematically  showing  the  relation  of  the  nuclei  of  these 
nerves  to  the  structures  of  the  medulla  and  their  connection  with  the  cerebral 
cortex. 


the  fourth  ventricle.     From  its  superficial  origin  it  passes  down- 
ward and  leaves  the  skull  at  the  central  part  of  the  jugular 


ANATOMY   AND    PHYSIOLOGY    OF    THE    CRANIAL    NERVES    135 

foramen.  In  this  foramen  the  nerve  presents  two  enlargements 
— the  superior,  called  the  jugular  ganglion,  and  the  inferior  and 
larger,  the  petrous  ganglion. 

This  nerve  is  distributed  to  the  tongue  and  pharynx,  being 
the  nerve  of  sensation  to  the  mucous  membrane  of  the  pharynx 
and  fauces.  It  is  a  special  nerve  of  taste,  being  distributed  to 
the  posterior  part  of  the  tongue. 

The  tenth  or  vagus  or  pneumogastric  nerve  is  a  mixed  nerve, 
its  motor  root  originating  in  cells  of  the  nucleus  ambiguus  in 
common  with  that  of  the  ninth  nerve.  Its  sensory  root  arises 
in  two  ganglionic  enlargements  on  the  front  of  this  nerve — the 
ganglion  of  the  root  and  the  ganglion  of  the  trunk.  The  motor 
root  emerges  and  the  sensory  root  enters  the  groove  between  the 
olivary  and  restiform  bodies,  below  the  ninth.  The  nerve 
passes  outward  and  downward  to  the  jugular  foramen,  through 
which  it  emerges  from  the  cranium.  In  this  foramen  the  nerve 
presents  its  tw^o  ganglionic  enlargements. 

The  tenth  nerve  has  a  wider  distribution  than  any  of  the 
other  cranial  nerves.  Passing  through  the  neck  and  thorax  to 
the  upper  part  of  the  abdomen,  it  supplies  the  organs  of  speech 
and  respiration  with  motor  and  sensory  fibers,  and  the  pharynx, 
esophagus,  stomach,  and  heart  with  motor  fibers.  The  nerve 
communicates  freely  with  the  ninth,  the  eleventh,  and  the  sym- 
pathetic ganglia  in  the  neck,  thorax,  and  upper  abdomen. 

The  Eleventh  or  Spinal  Accessory  Nerve. — This  nerve  con- 
sists of  two  parts — a  spinal  portion  and  an  accessory  portion. 
The  spinal  portion  originates  from  cells  in  the  spinal  cord,  situ- 
ated in  the  lateral  horn  of  the  gray  matter,  and  as  low  down  as 
the  fifth  cervical  segment.  These  fibers  appear  on  the  lateral 
aspect  of  the  cord,  behind  the  anterior  root,  and  form  a  trunk 
that  ascends  and  enters  the  skull  through  the  foramen  magnum. 
It  is  then  directed  outward  to  the  jugular  foramen,  where  it 
joins  the  accessory  portion.  The  accessory  portion  originates 
i;i  a  group  of  cells  situated  beneath  the  floor  of  the  fourth  ven- 
tricle, above  and  to  the  side  of  the  nucleus  of  the  twelfth  nerve. 
It  emerges  from  the  medulla  in  the  groove  between  the  olivary 
and  restiform  body,  below  the  tenth  nerve,  entering  the  jugular 
foramen,  where  it  joins  the  spinal  portion.     It  emerges  from  the 


136 


MANUAL   OF   NERVOUS   DISEASES 


cranial  cavity  through  the  jugular  foramen,  descends  in  front 
and  to  the  side  of  the  spinal  column,  giving  off  branches  to  the 
trapezius  and  to  the  sternocleidomastoid  muscle.  It  also  sends 
filaments  to  the  second  and  third  cervical  nerves,  and  assists  in 
the  formation  of  the  cervical  plexus.     (See  Figs.  26,  27,  32,  33.) 


Nucleus  ofHT 
Nucleus  /nfercalati/s  \ 
>3olita>-y  Aluclei^s 


Median  Longilud/na/  Fasc. 
t  Sensory  Nucleus  ofX. 

Des^endthtj  Roof  of  VM 

^^Jfesti'form  Body 


...Spinal  RooTofV 
,_.  Nucleus  Ambigi/us 
^  Subst,  Gelat/ftosa 


-Jitf .Arcuate  Fibers 
Ollvo  -Cerebe/lar  Fibers 
^Z^-FyfArcuafe  Fibers 
^"^erebe/Zo  0/ii/ary  Fibers 

^^Dorsa/ ' 
--Mesial') 
^^Hilum  of  Olive 
ArcLfale  Nucleus 


S Accessory  Olive 


Fig.  76. — Transverse  section  of  the  medulla  about  the  middle  of  the  olive, 
schematically  showing  the  nuclei  of  the  ninth,  tenth,  and  eleventh  nerves 
and  their  relation  to  the  structures  of  the  medulla  (Spalteholz). 

The  twelfth  or  hypoglossal  nerve  originates  from  a  group  of 
cells  lying  near  the  middle  line,  close  to  the  surface,  in  the  lower 
half  of  the  floor  of  the  fourth  ventricle.  Its  fibers  pierce  the 
reticular  formation,  and  appear  in  the  groove  between  the 
pyramid  and  the  olivary  body.  This  nerve  emerges  from  the 
cranial  cavity  through  the  anterior  condyloid  foramen,  and  is 
distributed  to  the  muscles  of  the  tongue.  It  sends  branches 
to  the  sternothyroid,  sternohyoid,  and  omohyoid  muscles. 


THE   SYMPATHETIC   NERVOUS   SYSTEM 

This  system  consists  of — (i)  A  series  of  ganglia  connected 
by  intervening  cords,  extending  from  the  skull  to  the  coccyx. 
There  are  two  sets  of  these  ganglia,  one  on  each  side  of  the  middle 
line  of  the  body,  partly  in  front  of  and  partly  on  each  side  of 
the  vertebral  column.  (2)  Three  great  gangliated  plexuses, 
situated  in  front  of  the  spine,  in  the  thoracic,  abdominal,  and 
pelvic  regions.     (3)  Numerous  smaller  ganglia.     (4)  Innumer- 


THE   SYMPATHETIC    NERVOUS    SYSTEM  137 

able  nerve-fibers.     (5)  Numerous  ganglia  situated  on,  or  con- 


Fig.  77. — Diagram  showing  gangliated  cord  on  one  side,  its  connections 
with  the  spinal  cord  and  with  the  various  ganghated  plexuses,  etc. 

nected  with,  the  cranial  nerves  and  their  branches  of  distribu- 
tion (Fig.  77). 


138  MANUAL   OF   NERVOUS   DISEASES 

Each  gangliated  cord  may  be  traced  upward  from  the  base  of 
the  skull  into  the  cranial  cavity  by  ascending  branches,  which 
pass  through  the  carotid  canal,  forming  a  plexus  on  the  internal 
carotid  artery  and  communicating  with  the  Gasserian  ganglion. 

In  the  cervical  region  there  are  three  sets  of  ganglia.  These 
connect  with  the  central  nervous  system  through  the  first  and 
second  dorsal  roots.  In  the  dorsal  region  there  are  twelve  pairs 
of  ganglia;  in  the  lumbar,  four;  and  in  the  sacral,  four  or  five. 
In  the  dorsal  and  lumbar  regions  the  ganglia  are  connected  with 
a  corresponding  segment  of  the  spinal  cord.  In  the  pelvis  the 
cords  converge  and  form  a  single  ganglion  in  front  of  the 
coccyx. 

The  three  gangliated  plexuses — the  cardiac,  in  the  thoracic 
cavity;  the  solar,  in  the  upper  abdominal  cavity;  and  the  hypo- 
gastric, in  front  of  the  promontory  of  the  sacrum — consist  of 
collections  of  nerves  and  cells.  They  distribute  branches  to  the 
viscera  of  the  thorax,  abdominal  cavity,  and  pelvis,  and  receive 
nerve-fibers  from  the  gangliated  cords  and  the  cerebrospinal 
nerves. 

Many  smaller  ganglia  are  situated  in  the  various  viscera — the 
heart,  the  lungs,  the  stomach,  the  uterus,  etc.  The  numerous 
nerve-fibers  that  help  to  make  up  the  sympathetic  system  are  of 
two  kinds — communicating,  by  means  of  which  the  ganglia 
communicate  with  each  other  and  with  the  cerebrospinal  nerves; 
disirihulory,  by  means  of  which  sympathetic  fibers  are  supplied 
to  all. the  internal  viscera,  the  muscular  coats  of  the  blood- 
vessels, the  glandular  structures,  special  organs,  and  unstriped 
muscles. 

From  the  thoracic  portion  of  the  gangliated  cords  are  given 
off  the  splanchnic  nerves,  which  communicate  with  the  solar 
plexus.  The  cardiac  plexus  is  situated  at  the  base  of  the  heart. 
The  epigastric  or  solar  plexus  is  behind  the  stomach,  in  front 
of  the  aorta  and  the  crura  of  the  diaphragm.  The  hypogastric 
plexus,  situated  in  front  of  the  promontory  of  the  sacrum,  dis- 
tributes branches  to  the  viscera  of  the  pelvic  cavity. 

When  fully  developed,  the  sympathetic  system  is  found  to 
consist  of  two  divisions:  The  first  division,  or  sympathetic 
system  proper,  often  called  the  vertebral  sympathetic,  consists 


THE    SYMPATHETIC    NERVOUS    SYSTEM  139 

of  a  chain  of  ganglia — the  cervical,  dorsal,  and  lumbar.  These 
ganglia  are  connected  with  the  spinal  cord  and  give  off  fibers  that 
pass  peripherally,  as  a  rule,  through  the  medium  of  secondarily 
formed  plexuses  or  ganglia,  to  the  viscera  of  the  thoracic  and 
abdominal  cavities,  to  the  vascular  system,  to  the  skin  with  its 
glands  and  appendages,  and  to  the  pelvic  viscera  and  genitalia. 

The  second  division  of  the  sympathetic  is  known  as  the  para- 
sympathetic or  autonomic  system.  The  fibers  that  make  up 
this  system  come  from  the  midbrain  and  enter  the  ciliary 
ganglion.  A  second  set  comes  from  the  glossopharyngeal  and 
the  pneumogastric  and  their  ganglia,  and  a  third  set  from  the 
lumbosacral  part  of  the  spinal  cord. 

The  Functions  of  the  Sympathetic  Nervous  System. — The 
sympathetic  system  appears  to  give  a  double  nervT  supply  to 
the  skin  and  its  appendages,  the  glands,  the  vascular  system, 
the  alimentary  system,  and  the  respiratory  system.  It  would 
appear  further  that  these  two  divisions — the  vertebral  s\tii- 
pathetic  and  the  autonomic — are  mutually  antagonistic  in 
their  functions.  For  example,  impulses  passing  through  the 
autonomic  fibers  by  the  oculomotor  nerv^es  of  the  ciliary  ganglia 
to  the  sphincter  of  the  eyes  cause  pupillary  contraction.  Im- 
pulses passing  through  the  vertebral  sympathetic,  reaching  the 
eyes  through  the  carotid  plexus  and  superior  divisions  of  the 
fifth  nerve,  cause  pupillary  dilatation.  The  vertebral  sym- 
pathetic contains  the  constrictors  for  the  blood-vessels,  whereas 
the  vagus  contains  the  dilators. 

The  vertebral  sympathetic  contains  and  transmits  impulses 
that  relax  the  smooth  muscle-fibers  of  the  esophagus,  the 
stomach,  etc.  The  pneumogastric  transmits  impulses  that 
cause  these  organs  to  contract.  In  the  pelvis  the  autonomic 
fibers  transmit  impulses  that  cause  contraction  of  the  smooth 
muscles  of  the  colon,  rectum,  urethra,  bladder,  etc.,  whereas 
the  vertebral  sympathetic  fibers  transmit  impulses  that  cause 
relaxation  of  these  muscles. 

It  has  been  more  or  less  definitely  shown  that  the  vertebral 
sympathetic  is  connected  with  the  spinal  cord  by  means  of  the 
white  rami  communicantes  which  leave  the  cord  by  the  anterior 
roots  immediately  after  the  formation  of  the  mixed  nerve. 


140  MANUAL   OF  NERVOUS   DISEASES 

There  is  apparently  every  reason  to  believe  that  the 
sympathetic  system  is  under  the  dominance  of  the  higher 
centers.  It  is  probably  little,  if  at  all,  influenced  by  the  will, 
but  is  certainly  dominated  by  the  moods  and  emotions.  Anger, 
fear,  pain,  etc.,  manifest  themselves  outwardly  by  sympathetic 
disturbances,  such  as  pallor,  flushing,  perspiration,  dryness  of 
the  mucous  membranes,  pupillary,  cardiac,  and  respiratory  dis- 
turbances, and  the  like.  The  sympathetic  system  also  possesses 
afferent  fibers,  which  pass  by  way  of  the  posterior  roots  to  the 
spinal  cord. 

Under  normal  conditions  the  functional  activity  of  the  viscera 
is  not  reflected  upon  consciousness.  In  diseased  states  of  the 
viscera  sensory  impulses  originating  in  them  are  reflected  upon 
consciousness  as  proceeding  from  areas  of  the  skin  supplied  by 
the  spinal  nerves  connected  with  the  segments  that  receive  the 
abnormal  sympathetic  impulses.  This  superficial  skin  local- 
ization, corresponding  to  the  various  organs,  has  been  carefully 
worked  out  by  Head  and  others.  Furthermore,  in  certain 
diseased  conditions,  as,  for  example,  in  neurasthenia  and  in 
hysteria,  in  which  the  individual  complains  of  peculiar  sensations, 
pain,  etc.,  in  his  viscera,  it  would  seem  that  these  afferent  sym- 
pathetic impulses  were  reflected  directly  upon  consciousness. 

This  would  seem  to  indicate  that  the  tone  of  the  various 
organs  of  the  body — of  the  circulatory  system,  the  skin,  the 
glands,  the  genito-urinary  system,  etc. — is  maintained  by  the 
constant  antagonistic  action  of  the  autonomic  system,  on  the 
one  hand,  and  the  vertebral  sympathetic  system,  upon  the  other. 
It  is  a  disturbance  of  the  balance  of  this  antagonistic  action, 
as  the  result  of  disease,  exhaustion,  toxemia,  emotional  distress, 
etc.,  that  gives  rise  to  the  various  symptom-complexes  and 
diseases  attributed  to  disturbed  activity  of  the  sympathetic  ner- 
vous system.  As  an  example  may  be  mentioned  the  vasovagal 
attacks  of  Gowers :  these  are  characterized  by  periodic  seizures, 
which  in  some  cases  resemble  epilepsy.  They  begin,  as  a  rule, 
with  a  peculiar  epigastric  sensation,  followed  by  palpitation  and 
forcible  heart  action,  and  sometimes  by  a  sensation  as  if  the 
heart  were  ceasing  to  beat,  a  sense  of  suffocation,  difficulty  in 
breathing,  a  fear  of  impending  death  or  as  if  some  great  calamity 


THE   SYMPATHETIC   NERVOUS   SYSTEM  141 

were  about  to  occur.  Simultaneously  there  may  exist  coldness 
of  the  extremities,  succeeded  by  a  clammy  perspiration  or  a 
burning  and  flushing  all  over  the  body.  The  attack  may  be 
accompanied  by  trembling  and  quivering  of  the  entire  body, 
and  may  last  from  a  few  minutes  to  several  hours. 

Further  consideration  of  the  sympathetic  system  shows  an 
intimate  relationship  between  the  sympathetic  and  the 
secretions  of  certain  of  the  ductless  glands,  which  belong 
to  the  chromophil  system.  Chromophil  cells  are  found  in 
the  medulla  of  the  suprarenal  glands,  in  the  sympathetic 
ganglia  and  plexuses,  in  the  kidneys,  accessory  suprarenals, 
carotid  bodies,  etc.  The  secretion  of  the  chromophil  tissue  is 
capable  of  causing  a  characteristic  reaction  in  structures  which 
are  innervated  by  the  sympathetic  system.  For  example: 
adrenalin,  which  is  a  product  of  the  suprarenal  medulla,  acts 
solely  on  the  tissues  innervated  by  the  vertebral  sympathetic, 
causing  a  rise  in  blood-pressure,  dilating  the  pupils,  and  exciting 
to  increased  activity  the  salivary  and  lacrimal  glands,  etc. 

It  is  through  the  normal  activity  of  the  vertebral  sympathetic 
system,  the  autonomic  system,  and  the  secretions  of  the  chromo- 
phil glandular  system  that  normal  vascular  tone,  normal  secre- 
tions, and  normal  activity  of  the  cardiac,  respiratory,  digestive, 
and  urinary  systems  are  brought  about  and  a  general  state  of 
well-being  and  health  is  maintained.  Disturbance  of  the  normal 
activity  of  the  sympathetic  nervous  system  gives  rise  to  a  feeling 
of  general  discomfort,  which  manifests  itself  as  nervousness, 
depression,  irritability,  anxiety,  etc. 

Disturbance  in  the  functions  of  the  sympathetic  may  also 
cause  pupillary  anomalies  and  disturbances,  trophic  and  vaso- 
motor disorders,  which  may  evidence  themselves  in  pathologic 
alterations  in  the  tonus  of  the  peripheral  vessels,  giving  rise  to 
such  conditions  as  erythromelalgia,  Raynaud's  disease,  migraine, 
intermittent  claudication,  angioneurotic  edema,  and  the  like. 


EXAMINATION   OF  THE   PATIENT 

HISTORY  AND   PHYSICAL  EXAMINATION 

It  is  especially  important,  in  the  study  of  patients  who  are 
suffering  with  nervous  and  mental  disorders,  that  a  thorough, 
complete,  and  correct  history  be  obtained.  This  is  at  times 
difficult  to  obtain  and  consumes  much  time.  In  some  cases  the 
physical  and  clinical  examination  of  the  patient  is  sufficient  to 
establish  the  diagnosis,  whereas  in  other  cases  the  diagnosis 
can  be  made  only  from  a  study  of  the  history. 

The  following  is  an  outline  for  obtaining  the  history  and  for 
making  an  examination  of  a  patient: 

The  name.  Age.  Sex.  Civil  state.  Date. 

Address.  Occupation. 

Complaint:  The  patient  should  be  allowed  to  state  in  his  or 
her  own  words,  without  suggestion  on  the  part  of  the  examiner, 
the  abnormality  of  function  for  which  he  or  she  has  consulted 
the  physician.  In  cases  in  which  the  patient  is  unable  to  talk, 
or  the  age  or  mental  condition  precludes  the  possibility  of  se- 
curing a  proper  statement,  the  nature  of  the  complaint  should 
be  ascertained  from  relatives  and  friends. 

It  has  been  my  experience  that  very  frequently  the  patient's 
statements  regarding  the  complaint  are  not  accurate,  and  one 
must  depend  upon  careful  inquiry  later  on  in  the  history  for 
correct  and  enlightening  information. 

Duration:  Care  must  be  exercised  in  accepting  the  statement 
as  to  the  duration  of  the  illness. 

Number  of  attacks:  If  the  first,  second,  third,  etc. 

Progress:  Is  the  condition  getting  better  or  w^orse? 

Course:  Is  the  patient  improving,  or  is  he  or  she  growing 
rapidly  or  slowly  worse,  or  is  the  course  stationary. 
142 


HISTORY   AND    PHYSICAL   EXAMINATION  1 43 

Family  History.  Under  this  head  careful  inquiry  should  be 
made  as  to  the  existence  of  nervous  or  mental  diseases,  tuber- 
culosis, rheumatism,  heart  or  kidney  alTections,  venereal  disease, 
drug  addictions,  alcoholism,  etc.,  existing  in  the  grandparents, 
the  parents,  the  brothers  and  sisters,  uncles,  aunts,  or  other 
members  of  the  patient's  family.  Inquiry  should  also  be  made 
as  to  the  age  at  which  members  of  the  immediate  family  died,  and 
as  to  the  cause  of  death  in  each  case.  The  object  in  making  a 
careful  inquiry  into  the  existence  of  disease  in  the  family  or  the 
ancestors  is  to  learn  whether  the  affliction  is  one  of  a  certain 
number  of  nervous  disorders  known  as  familial  diseases,  and 
which  occur  usually  in  succeeding  generations.  There  are  also 
numbers  of  diseases  that  show  a  marked  hereditary  tendency, 
existing  in  the  parents  and  children.  Chronic  disease,  drug 
addictions,  alcoholism,  unfavorable  living  conditions,  etc.,  in 
the  parents  predispose  to  the  occurrence  of  nervous  and  mental 
affections  in  the  offspring. 

Past  History.  Careful  inquiry  should  be  made  into  the  past 
history  to  ascertain  the  living  conditions,  the  health,  the  occur- 
rence of  injury,  worry,  shock,  etc.,  experienced  by  the  mother 
during  the  time  she  was  pregnant  with  the  patient.  The 
conditions  under  w^hich  the  patient  was  born,  w^hether  the  labor 
was  prolonged,  difficult,  instrumental,  or  normal.  The  diseases 
which  occurred  during  infancy  and  childhood,  w^hether  they  were 
attended  by  any  unusual  symptoms,  or  whether  they  wxre  fol- 
lowed by  complications,  and  if  so,  how  these  complications  af- 
fected the  individual,  whether  the  individual  took  his  nourish- 
ment normally,  the  age  at  which  the  teeth  first  appeared,  when 
he  first  began  to  crawl,  walk,  and  talk;  the  occurrence  of  con- 
vulsions, of  injury,  or  of  skin  eruptions;  the  progress  made  at 
school,  as  to  physical  development.  During  later  childhood, 
was  there  any  disease,  injury,  convulsions,  or  venereal  infection? 
if  a  female,  the  age  at  w^hich  menstruation  first  appeared,  its 
character,  and  the  effect  its  occurrence  had  upon  the  general 
disposition  of  the  patient.  The  age  at  which  the  appearance 
of  the  patient  and  the  development  of  the  sexual  organs  indi- 
cated a  change  from  childhood  to  adolescence.  Inquiry 
should  be  made  as  to  the  occurrence  of  disease  later  in  life, 


144  MANUAL  OF  NERVOUS  DISEASES 

of  injury,  of  the  habits  as  regards  alcohol,  drugs,  work,  and 
recreation,  and  the  existence  of  venereal  disease.  The  number  of 
children,  the  number  of  miscarriages  and  the  causes  that  brought 
them  about,  the  age  at  which  the  patient  was  married,  the  state 
of  health  of  the  husband  or  wife,  of  the  children,  the  home 
conditions,  whether  congenial  and  happy  or  irritating  and  un- 
happy. It  is  important,  in  eliciting  the  past  history  of  the  indi- 
vidual, to  assist,  by  judicious  questioning,  the  memory  of  the 
patient  or  his  friends,  so  that  an  accurate  account  of  the  past 
life  of  the  patient  may  be  obtained. 

It  is  important  to  remember  that  the  patient  may  uninten- 
tionally give  unreliable  information.  If,  therefore,  the  history 
is  one  of  unusual  conditions,  it  should  be  confirmed  by  further 
questioning  as  to  details. 

Present  Illness:  It  is  most  important,  in  getting  an  account 
of  the  illness  for  which  the  patient  consults  a  physician,  to  secure 
this  information  in  as  nearly  a  correct  chronologic  order  as 
possible.  Although  it  is  permissible,  and  even  advisable,  to 
allow  the  patient  to  state  his  complaint  in  his  own  words,  it  is 
necessary  at  this  time  to  insist  upon  his  giving  you  an  accurate 
account  of  his  symptoms. 

I  find  it  advisable  to  have  the  patient  or  his  friends  state 
the  first  indication  that  made  him  think  he  was  ill,  the  mode 
of  onset,  whether  it  began  gradually  or  developed  suddenly, 
whether  intermittent  or  paroxysmal  in  character,  if  there  were 
intervals  between  the  symptoms,  the  length  of  the  intervals,  etc. 
I  then  have  the  patient  recount,  as  well  as  he  is  able,  when  and 
how  subsequent  symptoms  manifested  themselves,  also  the  dis- 
tribution of  the  symptoms, — whether  one  part,  several  parts, 
or  the  entire  body  was  affected, — and  the  progress  of  the  illness, 
from  the  date  of  onset  up  to  the  present  time. 

Having  obtained  a  correct  and  full  history  from  either  the 
patient  or  his  friends,  preferably  from  both,  the  next  step  is  to 
make  a  thorough  examination  of  the  patient.  I  wish  to  empha- 
size here  the  importance  of  making  a  careful  and  complete 
physical  examination,  for  it  is  my  belief  that  if  proper  physical 
examinations  were  made  of tener,  fewer  cases  would  be  diagnosed 
as  neurasthenia,  hysteria,  functional  neurosis,  etc.,  and  many 


PHYSICAL  EXAMINATION  1 45 

would  be  found  to  be  diseased  conditions  of  the  kidneys,  heart, 
blood-vessels,  blood,  ductless  glands,  etc. 


PHYSICAL  EXAMINATION 

The  following  points  should  be  noted:  The  appearance,  the 
expression,  and  the  weight  of  the  patient.  The  blood-pressure 
should  be  taken  and  the  intelligence  tested.  Some  idea  of  the 
intelligence  of  the  patient  is  obtained  in  taking  the  history — 
whether  or  not  the  patient  comprehends  well  and  quickly; 
whether  his  thinking  processes  are  normal  or  slow,  and  whether 
the  comprehension  is  poor  and  the  individual  stupid.  In 
arriving  at  a  correct  conclusion  regarding  the  intelligence  of  the 
patient,  one  must  always  take  into  consideration  the  age,  the 
station  in  life,  etc. 

The  Skin. — This  should  be  examined  for  scars,  eruptions,  or 
swellings.  The  state  of  its  nutrition — whether  it  is  thin  and 
glossy,  or  thick  and  scaly;  whether  moist  or  dry;  the  presence  of 
pigmentation  or  if  absorption  of  pigment  has  taken  place;  the 
state  and  condition  of  the  skin  appendages — the  hair  and 
nails. 

The  Bones  and  Joints. — Note  the  presence  of  any  deformities, 
fractures,  diseases  of  the  joints,  or  malformations. 

The  Month,  Nose,  and  Throat. — ^The  condition  of  the  teeth  and 
of  the  tonsils  should  be  learned,  as  well  as  the  presence  of 
eruptions,  ulcerations,  or  scars  on  the  mucous  membranes  of  the 
mouth,  tongue,  nose,  or  throat;  the  presence  of  adenoids;  the 
amount  of  breathing  space;  abnormalities  in  the  nose  and  palate. 

The  Eyes  and  Ears. — Are  the  eyes  set  normally  in  the  orbits, 
or  is  there  a  protrusion  or  sinking,  swelling,  etc.?  Ascertain 
whether  the  ocular  movements  are  normal,  and  whether  the 
pupils  are  regular,  irregular,  and  active.  Determine  whether 
the  ears  are  properly  set,  if  there  are  any  deformities  or  tophi, 
and  whether  the  two  ears  are  symmetric  in  shape. 

The  Respiratory  System. — Careful  examination  should  be  made 
of  the  lungs  and  of  the  larynx. 

The  Cardiovascular  System. — ^A  thorough  examination  should 
be  made  of  the  heart,  giving  attention  to  its  size  and  position, 
10 


146  MANUAL  OF  NERVOUS  DISEASES 

the  presence  or  absence  of  murmurs,  the  rate  and  the  rhythm  of 
the  heart-beat.  The  blood-vessels  should  be  examined  for  the 
presence  of  sclerosis,  degeneration,  etc.  In  examining  the  blood- 
vessels it  is  important  to  learn  the  condition  of  the  temporals, 
the  radials,  the  dorsalis  pedis  arteries,  the  aorta,  and  the  veins. 

Glandular  Enlargements  and  Tumors. — The  entire  body  should 
be  carefully  examined  for  the  presence  of  glandular  enlargements 
or  tumors. 

Gastro-intestinal  Symptoms. — Careful  examination  of  the 
functions  and  activities  of  the  stomach  and  intestines  should  be 
made  in  those  cases  in  which  the  symptoms  point  to  the  gastro- 
intestinal tract.  The  absence  or  presence  of  constipation  should 
also  be  noted. 

Genito-urinary  System. — In  all  cases  complete  examination, 
both  macrosopic  and  microscopic,  of  the  urine  should  be  made, 
including  the  test  for  indican.  Where  indicated,  a  careful 
examination  of  the  sexual  organs,  the  urethra,  the  bladder,  the 
ureter,  and  the  kidneys  should  be  made. 

The  Rectum  and  Pelvis. — Careful  inquiry  should  be  made  as 
to  the  presence  or  absence  of  hemorrhoids,  fissures,  ulcerations, 
and,  in  women  who  have  borne  children,  as  to  the  condition  of 
the  perineum,  etc.  When  symptoms  point  in  this  direction,  an 
internal  examination  is  to  be  made.  Purulent  discharges  from 
any  portion  of  the  body  should  be  carefully  examined  micro- 
scopically. 

The  Blood. — ^The  examination  of  the  blood  should  include  a 
differential  count,  the  hemoglobin  estimate,  and  a  white  and 
red  cell  count.  The  Wassermann  test  is  often  important  and 
many  times  is  absolutely  necessary. 

The  Cerebrospinal  Fluid. — ^This  should  be  examined  in  all 
cases  that  are  difficult  of  diagnosis  or  where  there  is  any  ques- 
tion as  to  the  cause  of  the  illness,  and  in  cases  in  which  this 
examination  is  indicated.  This  examination  should  include  a 
cell  count,  the  sugar  test,  the  Wassermann  test,  the  specific 
gravity,  etc. 

In  many  cases  it  is  well,  before  proceeding  to  make  an  exam- 
ination of  the  nervous  system,  to  make  a  test  of  the  mentality 
of  the  patient. 


EXAMINATION    OF    THE    NERVOUS    SYSTEM  147 

The  Memory. — By  proper  questioning  one  can  readily  deter- 
mine whether  the  memory  is  disturbed  and  if  the  disturbance 
is  diffuse  or  is  impaired  only  for  recent  or  remote  events. 

Orientation. — By  proper  questioning  it  is  simple  to  determine 
if  the  patient  recognizes  his  surroundings,  i.  e.,  orientated  for 
place;  whether  he  recognizes  persons  around  him,  i.  e.,  orien- 
tated for  persons ;  and  whether  he  is  familiar  with  the  passage 
of  time,  such  as  time  of  day,  day  of  week,  etc.,  i.  c,  orien- 
tated for  time. 

Illusions,  hallucinations,  delusions  can  be  discovered  by  ques- 
tioning the  patient,  or  by  careful  inquiry  from  the  relatives 
and  friends. 

Disturbances  of  Conduct  and  of  the  Emotions. — These  may  be 
discovered  during  the  course  of  the  examination,  or  a  history  of 
the  same  may  be  obtained  from  the  family  or  friends. 

EXAMINATION  OF  THE   NERVOUS   SYSTEM 

Speech.— In  examining  for  speech  defects  one  should  note 
any  disturbance  of  phonation,  the  existence  of  stuttering,  ex- 
plosive or  monotonous  speech.  The  tone  of  the  voice,  whether 
low  or  loud,  and  the  elision  of  syllables  or  words  should  be  noted; 
also  w^hether  any  of  the  various  types  of  aphasia  exists.  In 
examining  for  speech  defects  one  must  ascertain  whether  the 
patient  can  or  cannot  voluntarily  express  ideas  in  words;  whether 
he  can  name  objects  that  he  sees;  whether  he  can  express  written 
sentences  in  words  or  repeat  w^ords  or  sentences  that  he  hears. 
Voluntary  speech  is  disturbed  in  stuttering,  stammering,  in 
some  diseased  conditions,  such  as  weakness  or  paralysis  of  the 
larynx,  vocal  cords,  tongue,  lips,  and  pharynx,  in  general  bodily 
weakness,  etc. 

When  the  individual  is  unable  to  repeat  test  words,  as,  for 
example,  "statistician,"  "perturbation,"  "German  riding  ar- 
tillery brigade,"  etc.,  without  the  elision  or  reduplication  of 
syllables,  letters,  or  words,  there  exists  a  condition  in  which  the 
higher  cerebral  associative  centers  are  involved.  When  the 
individual  is  unable  to  express  his  ideas  in  words,  whether  these 
ideas  originate  in  the  visual  field,  in  the  sensory  field,  on  in  the 


l^ 


148  MANUAL   OF   NERVOUS  DISEASES 

intellectual  field,  and  there  exists  no  physical  impediment,  such 
as  local  diseases  of  the  tongue  or  larynx,  etc.,  for  the  expression 
of  these  ideas,  a  condition  known  as  jCphasi0?  exists. 

Gail. — The  individual  should  be  asked  to  walk,  and  any 
abnormality  noted.  The  gait  may  be  uncertain,  ataxic,  stagger- 
ing, hemiplegic,  spastic,  steppage,  shuffling,  diplegic,  etc. 

Examination  of  the  Motor  System. — Muscular  Development 
and  Muscular  Nutrition. — Careful  examination  should  be  made 
for  the  presence  of  muscular  atrophy  or  hypertrophy,  and  if 
either  is  present,  the  degree  and  the  location  should  be  carefully 
noted.  The  limbs  and  the  two  sides  of  the  body  should  be 
compared  with  each  other  by  actual  measurement. 

Motor  Power. — ^The  strength  of  the  flexors  and  extensors  of 
the  extremities  and  of  the  two  sides  of  the  body  should  be  com- 
pared, and  any  weakness  or  paralysis  should  be  carefully  noted 
as  to  extent  and  distribution. 

Muscle  Tone. — Examination  should  be  made  to  ascertain 
whether  the  muscle  tone  is  increased,  decreased,  or  normal, 
and  if  disturbed,  the  degree  and  distribution  should  be  noted. 
Abnormalities  are  discovered  by  comparing  the  two  sides  of  the 
body  with  each  other,  if  only  one  side  is  diseased,  or  if  there  is 
a  general  involvement,  by  comparing  the  state  of  the  muscle 
tone  in  the  affected  individual  with  the  muscle  tone  of  a  normal 
person. 

Abnormal  Movements. — These  may  occur  constantly  or  at 
intervals.  They  may  be  very  limited  in  extent,  being  insufficient 
to  bring  about  twitching  of  the  trunk  or  extremities,  or  they 
may  be  so  extensive  as  to  occasion  violent  contractions  of  the 
trunk  or  extremities. 

The  following  are  the  types  of  abnormal  movements :  Fibrillary 
tremors,  which  are  contractions  of  muscle-fibers  or  groups  of 
muscle-fibers,  producing  wave-like  twitchings  in  the  muscles. 
They  occur  in  degenerative  diseases  of  the  spinal  cord,  in  which 
there  is  a  gradual  involvement  of  the  anterior  horn  cells;  also 
in  toxic  conditions  and  upon  exposure  to  cold,  etc. 

Other  Forms  of  Tremors. — ^Tremors  may  be  rapid  or  slow  in 
rate,  and  they  may  be  limited  or  wide-spread  in  extent.  They 
may  be  passive;  that  is,  occur  while  the  affected  part  is  at  rest,  or 


EXAMINATION   OF   THE   NERVOUS    SYSTEM  1 49 

they  may  be  of  the  intention  type,  that  is,  occur  during  the  volun- 
tary movements  of  the  affected  part.  Some  passive  tremors  can 
be  inhibited  upon  voluntary  movement,  and  some  are  rendered 
very  much  worse  during  voluntary  activity.  Nearly  all  tremors 
are  intensified  upon  emotional  excitement.  Tremors  occur  very 
commonly  in  both  general  and  nervous  diseases.  They  are  a 
prominent  symptom  in  senility,  exophthalmic  goiter,  paralysis 
agitans,  multiple  sclerosis,  general  paresis,  etc.  They  may  affect 
any  portion  of  the  body,  but  most  frequently  involve  the  upper 
extremities,  the  tongue,  the  lips,  and  the  head. 

Choreiform  Movements. — ^These  movements  are  irregular, 
purposeless,  inimitable  muscle  contractions,  which  occur  at 
irregular  intervals,  varying  in  extent  from  movements  so  mild 
as  to  be  perceptible  only  under  careful  observation,  to  movements 
that  are  so  exaggerated  as  to  result  in  violent  contractions  of 
the  entire  body.  These  movements  usually  involve  the  upper  ex- 
tremities and  the  face,  but  may  involve  any  portion  of  the  body. 

•  Athetoid  Movements. — ^These  are  caused  by  involuntary  muscle 
contractions,  which  bring  about  wave-like  or  worm-like  move- 
ments of  the  distal  parts  of  the  extremities  and  sometimes  of  an 
entire  extremity.  These  movements  are  not  under  voluntary 
control,  and  are  due  to  cerebral  disease,  occurring  most  fre- 
quently in  congenital  or  early  acquired  cerebral  disorders  (Figs. 

78,  79)- 

Spasms '  are  contractions  of  muscles  or  groups  of  muscles 
due  to  either  a  direct  or  a  reflex  stimulation  of  a  nerve.  They 
are  usually  limited  in  extent. 

Convulsions  are  more  or  less  extensive  contractions  and  re- 
laxations of  groups  of  muscles,  which  bring  about  movements 
of  the  extremities,  head,  trunk,  or  entire  body.  They  may  or 
may  not  be  attended  by  loss  of  consciousness,  and  are  due  to 
either  direct  or  reflex  irritation  of  the  cerebrospinal  motor  centers. 

Coordination  is  tested  for  by  having  the  patient  touch  the 
tip  of  his  nose  with  the  finger  with  his  eyes  closed;  by  having 
him  bring  the  two  index-fingers  together,  making  the  arms  de- 
scribe the  arc  of  a  large  circle,  with  his  eyes  open  and  then  w^ith 
his  eyes  closed;  by  having  him  touch  the  knee  of  one  side  with 
the  heel  of  the  foot  of  the  opposite  side,  directing  him  to  ele- 


ISO 


MANUAL   OF   NERVOUS   DISEASES 


vate  the  leg  and  bring  the  heel  directly  down  so  as  to  touch  the 
knee;  this  should  be  done  with  the  eyes  both  open  and  closed. 


Fig.  78. — Patient  showing  athetoid  movements  and  facial  spasm. 


Romberg's  phenomenon  is  a  test  for  coordination  and  equilib- 
rium. The  patient  should  stand  with  the  feet  close  together, 
both  at  the  heels  and  toes,  and  with  the  eyes  closed. 


EXAMINATION    OF    THE    NERVOUS    SYSTEM  151 

In  all  these  tests  the  inability  of  the  patient  to  perform  the 
desired  action  quickly  and  accurately  is  an  indication  that  there 
is  an  interference  with  the  reception  of  sensory  stimuli,  the 
transmission  of  these  stimuli  to  the  higher  centers,  the  elabora- 
tion in  the  higher  centers,  or  the  ability  of  these  stimuli  to 
influence  reflexly  the  motor  mechanism  controlling  the  desired 
action. 

Diadokokinesis. — This  is  tested  for  by  having  the  patient 
extend  both  hands  in  front  of  him,  arid  rapidly  rotate  the  hands 


Fig.  79. — Hand  of  patient  sho\\-ing  athetoid  movements. 

and  forearms  in  their  long  axes.  Under  normal  conditions  this 
rotation  is  carried  out  regularly  and  equally  in  both  arms.  In 
diseased  conditions  in  which  there  is  marked  interference  with 
the  cerebellar  control  of  coordinate  movements  there  is  a  dis- 
turbance in  the  regularity  and  similarity  of  rotation  in  the  two 
arms.  This  condition  is  kno-^n  as  adiadokokinesis,  and  is 
evidenced  by  an  irregular  and  unequal  rotation  of  the  two 
arms. 


152 


MANUAL   OF   NERVOUS   DISEASES 


REFLEXES 

The  Deep  Reflexes — The  important  deep  reflexes  are  those 
of  the  knee,  the  tendo  Achilhs  reflex,  the  triceps,  the  biceps,  the 
periosteoradial,  the  jaw  reflex,  and  the  corrugator  superciUi 
reflex.  These  reflexes  are  tested  for  by  having  the  muscles 
connected  with  the  part  of  the  body  to  be  tested  in  a  state  of 
partial  tension.  The  individual's  attention  should  be  dis- 
tracted from  the  part  of  the  body  under  examination,  and  a 


Fig.  80. — Position  of  patient  in  testing  for  tendo  Achillis  reflex. 


quick  sharp  tap  should  be  made  upon  the  tendon  connected 
with  the  muscle  to  be  tested. 

The  Tendo  Achillis  Reflexes. — The  patient  may  kneel  on  a 
chair,  with  both  feet  extending  over-  the  edge.  The  tendo 
AchiUis  should  be  tapped  with  some  instrument,  preferably  a 
pleximeter.  When  the  reflex  is  present  there  will  be  a  sharp, 
quick  contraction  of  the  posterior  leg  muscles  and  the  foot  will 


REFLEXES  1 53 

be  extended  If  the  patient  is  in  bed  this  reflex  can  be  tested 
for  by  slightly  flexing  the  leg  on  the  thigh,  grasping  the  foot, 
and  making  slight  traction  on  the  posterior  leg  muscles  by 
flexing  the  foot  on  the  leg,  distracting  the  patient's  attention,  and 
tapping  the  tendo  Achillis  (Figs.  80,  81). 


Fig.  81. — Position  of  patient  in  testing  for  tendo  Achillis  reflex. 

The  Knee  Reflexes. — The  patient  should  preferably  be  in  the 
sitting  position,  with  the  leg  flexed  on  the  thigh,  at  an  angle  of 
about  100  degrees,  or  he  may  cross  the  legs  and  allow  one  leg 
to  swing  loosely  over  the  other  (Figs.  82,  83).  On  tapping  the 
tendon  of  the  quadriceps  extensor  muscle,  if  the  reflex  is  present, 
a  contraction  results,  bringing  about  a  more  or  less  marked 
extension  of  the  leg. 


154  MANUAL   OF   NERVOUS   DISEASES 

The  Periosteoradial  Reflex. — This  is  tested  for  by  having  the 
patient  pronate  the  hand  on  the  forearm  and  flex  the  forearm  on 
the  arm.  The  examiner  may  either  support  the  forearm  in  his 
hand  or,  better  still,  have  the  patient  sit  in  an  arm-chair  and 
allow  the  arm  to  rest  on  the  arm  of  the  chair  (Fig.  84).  By 
tapping  sharply  on  the  radius,  just  above  the  wrist-joint,  if 


Fig.  82.— Position  of  patient  in  testing  for  knee  reflexes. 

this  reflex  is  present,  there  results  an  extension  of  the  hand  on 
the  forearm  and  a  contraction  of  the  supinator  longus  muscle. 
The  Biceps  Reflex.— Thiz  reflex  is  best  tested  for  by  having  the 
forearm  semiflexed  on  the  arm.  The  examiner  should  then  place 
his  finger  over  the  biceps  tendon  (Fig.  85),  and  tap  the  finger 
over  the  tendon  with  a  pleximeter;  w^hen  this  reflex  is  present, 
there  results  a  contraction  of  the  biceps  and  sometimes  flexion 
of  the  forearm. 


REFLEXES  1 55 

The  Triceps  Reflex. — The  presence  or  a])sence  of  this  reflex 
is  tested  for  by  having  the  patient  flex  the  forearm  on  the  arm 
(Fig.  86).  The  examiner  may  then  either  support  the  arm  or 
the  arm  may  rest  over  the  back  of  a  chair.  The  tendon  of  the 
triceps  muscles,  immediately  above  its  attachment  to  the 
olecranon,  is  tapped  with  a  pleximeter;  when  this  reflex  is  present, 
there  occurs  a  contraction  of  the  triceps  muscles  and  an  extension 
of  the  forearm. 


Fig.  83. — Position  of  patient  in  testing  for  knee  reflexes. 

The  jaw  reflex  is  best  tested  for  by  having  the  patient  relax 
the  muscles  of  mastication  slightly,  thereby  allowing  the  jaws  to 
be  slightly  separated.  The  examiner  then  places  his  finger  upon 
the  lower  jaw,  between  the  lip  and  the  chin  (Fig.  87).  The 
patient's  attention  is  distracted,  and  a  sharp,  quick  tap  is  made 
upon  the  examiner's  finger;  when  the  jaw  reflex  is  present,  there 
is  a  sudden  closing  of  the  jaws. 


156 


MANUAL   OF   NERVOUS   DISEASES 


The  corrugator  supercilii  reflex  is  best  tested  for  by  having 
the  patient  look  downward  and  relax  the  upper  eyelids.  A 
gentle  but  quick  tap  is  given  just  above  the  eyebrows,  about 
J  to  I  inch  from  the  midline;  when  this  reflex  is  present,  fol- 
lowing the  tap  there  occurs  an  elevation  of  the  eyebrows. 

The  deep  reflexes  may  be  present  and  yet  be  difficult  to  bring 
out.     This  is  often  due  to  the  fact  that  it  is  impossible  for  the 


Fig.  84. — Position  of  patient  in  testing  for  periosteoradial  reflex. 


patient  to  distract  his  attention  from  the  part  under  examination, 
and  he  consequently  voluntarily  inhibits  the  production  of  the 
reflex.  Under  these  conditions  the  Jendrassik  method  of 
reinforcement  may  be  successful.  This  consists  of  distracting 
the  patient's  attention  to  another  part  of  his  body  by  having 
him  voluntarily  exert  some  motor  activity  not  connected  with 
the  part  under  examination;  thus,  in  testing  the  lower  extremi- 
ties, he  is  requested  to  clasp  his  two  hands  together,  and  at  a 


REFLEXES 


157 


word  of  command  from  the  examiner  to  exercise  as  much  pres- 
sure as  possible,  with  his  hands  against  each  other  (Fig.  88). 
His  voluntary  eflorts  are  thus  directed  toward  the  movements 
of  his  arms  and  hands  while  his  legs  are  under  examination. 
In  examining  the  upper  extremities,  the  attention  my  be  directed 
toward  movements  of  the  legs. 

The  deep  reflexes  are  increased  in  all  conditions  in  which  the 
inhibiting  power  from  the  higher  centers  is  lessened  or  destroyed, 


Fig.  85. — Position  of  patient  in  testing  for  biceps  reflex. 


except  in  complete  transverse  lesions  of  the  spinal  cord,  The 
deep  reflexes  are  decreased  or  lost  in  all  conditions  in  which  there 
is  an  interference  with  or  a  destruction  of  the  reflex  arc. 

The  Superficial  Reflexes. — The  important  superficial  reflexes 
are  the  plantar,  the  Babinski,  the  cremasteric,  the  abdominal, 
the  corneal,  and  the  pharyngeal. 

The  plantar  reflex  is  tested  for  by  irritating  the  sole  of  the 


158 


MANUAL   OF  NERVOUS   DISEASES 


foot  with  the  examiner's  fingers,  or  lightly  with  some  object. 
As  a  result  of  this  stimulation  there  occurs  first  a  flexion  of  the 
toes.  In  sensitive  individuals,  or  where  the  stimulation  has 
been  excessive,  in  addition  to  the  flexion  of  the  toes  there  is  a 
flexion  of  the  foot,  and  in  some  cases  a  retraction  of  the  entire 
leg  {retraction  reflex) . 

The  Bahlnskl  reflex  is  tested  for  by  stroking  the  outer  side  of 
the  plantar  surface  of  the  foot  firmly  from  the  heel  toward  the 


Fig.  86. — Position  of  patient  in  testing  for  triceps  reflex. 


toes  (Fig.  89) ;  when  this  reflex  is  present,  there  occurs  a  dorsal 
extension  of  the  great  toe,  and  in  perfectly  typical  cases  a  fan- 
like spreading  out  of  the  other  toes.  Oppenheim  and  Gordon 
have  each  described  a  method  for  producing  the  same  reflex — the 
former,  by  irritating  the  inner  side  of  the  lower  end  of  the  tibia, 
and  the  latter,  by  irritation  and  pressure  along  the  outer  surface 
of  the  tibia.    This  reflex  is  present  normally  in  children  less 


REFLEXES 


159 


than  two  years  old  and  sometimes  even  in  older  children.  When 
this  reflex  is  present,  except  in  the  case  of  infants,  it  is  practically 
always  indicative  of  a  disease  process  that  has  resulted  in  de- 
struction of  or  caused  an  interference  with  conduction  in  the 
corticospinal  motor  pathways. 


Fig.  87. — Position  of  patient  in  testing  for  jaw  reflex. 


The  cremasteric  reflexes  are  best  tested  for  by  gently  stroking 
the  inner  aspect  of  the  upper  thigh,  which  causes  retraction 
of  the  testicle  upon  the  same  side. 

The  abdominal  reflexes  are  tested  for  by  quickly  and  lightly 
stroking  the  abdominal  walls.  This  brings  about  a  contraction 
of  the  abdominal  muscle  situated  beneath  the  irritated  area, 
and  we  thus  may  have  the  hypogastric  or  epigastric  abdominal 
reflex. 


i6o 


MANUAL   OF   NERVOUS   DISEASES 


The  corneal  and  conjunctival  reflexes  are  tested  for  by  suddenly 
approaching  an  object  toward  the  eyes,  or  by  lightly  touching 
the  conjunctiva  or  cornea,  which  produces  a  quick  contraction  of 
the  sphincter  palpebra. 

The  pharyngeal  reflex  is  best  tested  for  by  touching  the  base  of 
the  tongue  or  the  pharyngeal  walls;  when  this  reflex  is  present, 


tFig.  88. — Illustrating  Jendrassik's  method  of  reinforcing  the  reflexes. 

there  occurs  a  contraction  of  the  pharyngeal  muscles,  retching, 
and  spasm  of  respiration. 

The  superficial  reflexes  may  be  increased  in  the  absence  of 
any  pathologic  conditions,  and,  in  fact,  they  are  frequently 
increased  in  normal  individuals.  The  absence  of  the  superficial 
reflexes  may  occur  in  organic  diseases ;  in  which  there  is  a  loss  of 
sensation,  where  extensive  destructive  processes  have  taken 


REFLEXES 


l6l 


place  in  the  corticospinal  pathways,  in  functional  neurosis,  and 
in  various  diseases  other  than  those  of  the  nervous  system.  The 
loss  of  the  superficial  reflexes,  with  the  exaggeration  of  the  deep 
reflexes,  is  always  very  suggestive  of  an  organic  disease  of  the 
central  nervous  system. 

Organic  Reflexes. — Rectal  Reflex. — The  reflex  activity  of  the 
rectal  sphincter  is  best  tested  for  by  inserting  the  finger  into  the 


Fig.  89. — Babinski's  reflex. 


rectum.  In  those  cases  in  which  there  is  an  increase  in  the  rectal 
reflex  the  attempt  will  bring  about  a  quick  contraction  of  the 
sphincter;  where  the  rectal  reflex  is  lost,  the  examining  finger 
discovers  a  relaxation  of  the  sphincter,  and  the  presence  of  the 
finger  does  not  produce  contraction. 

Vesical  Reflexes. — In  exaggeration  of  this  reflex  there  occurs 
retention  of  urine,  with  dilatation  of  the  bladder.  WTiere  the 
reflex  spasm  of  the  sphincter  muscle  is  not  too  extreme,  after 


II 


1 62  MANUAL   OF   NERVOUS   DISEASES 

moderate  dilatation  there  occurs  a  constant  dribbling  or  an 
occasional  involuntary  emptying  of  the  bladder.  Where  the 
reflex  spasm  of  the  sphincter  is  excessive,  rupture  of  the  bladder 
wall  may  take  place  unless  the  bladder  be  emptied  by  catheter- 
ization. Where  the  vesical  reflex  is  lost,  relaxation  of  the  vesical 
sphincter  and  constant  dribbling  of  urine  occur. 

Where  voluntary  control  of  the  rectal  and  vesical  sphincters 
is  lost,  if  attended  by  spastic  contraction  of  the  sphincters,  this 
is  due  to  a  pathologic  process  that  affects  the  corticospinal 
pathways;  when  the  loss  of  control  is  accompanied  by  a  relaxed 
condition  of  the  sphincters,  the  pathologic  process  involves  the 
reflex  arc  between  the  bladder  or  rectum,  or  both,  and  the  lumbar 
enlargement  of  the  spinal  cord. 

SENSORY  FUNCTIONS 

Epicritic  or  Light  Sensibility. — Under  this  form  of  sensation 
are  grouped  tactile  sense,  pain  sense,  temperature  sense,  and  the 
ability  to  locate  milder  forms  of  stimulation. 

Tactile  Sense. — In  testing  for  the  sense  of  touch  one  uses  a 
camel's-hair  brush,  a  feather,  a  bit  of  absorbent  cotton,  or  any 
object  with  which  a  light  touch  may  be  made.  The  patient  is 
directed  to  close  the  eyes,  and  to  indicate  promptly,  either  by 
word  or  action,  that  he  is  conscious  of  the  touch.  The  rapidity 
of  perception,  the  ability  to  locate  the  stimulus,  and  a  comparison 
of  the  correctness  of  the  perceptions  in  similarly  situated  areas 
are  to  be  noted. 

Pain  Sensation. — Similar  tests  are  to  be  made  for  the  per- 
ception of  pain  sensation,  using  in  this  case  a  sharp  and  a  blunt 
object,  such  as  the  point  and  head  of  a  pin.  Rapidity  of  per- 
ception, the  location  of  the  stimulation,  and  the  comparison  of 
the  degree  of  stimulation  in  similarly  situated  areas  are  to  be 
noted. 

Temperature  Sensation. — This  form  of  sensation  is  to  be  tested 
for  by  using  two  test-tubes,  the  one  filled  with  hot  and  the  other 
with  cold  water.  The  temperature  of  the  hot  water  should  be 
between  105°  and  110°  F.;  that  of  the  cold  water  should  be 
about  70°  F.     If  the  temperatures  are  very  much  above  or  below 


SENSORY    FUNCTIONS  1 63 

these  points,  the  patient  may  perceive  them  as  pain,  rather  than 
as  heat  and  cold.  The  various  portions  of  the  body  should  be 
touched  alternately  with  the  tube  containing  the  hot  and  the 
cold  water,  and  the  patient  is  to  indicate  which  one  is  being 
used.  In  making  this  examination  the  rapidity  of  the  perception, 
the  correctness,  the  ability  to  localize,  and  the  comparison  in 
similarly  situated  areas  in  the  two  sides  of  the  body  are  to  be 
noted. 

Protopathic  or  coarse  sensibility  is  that  form  of  sensibility 
whereby  the  patient  is  conscious  of  stimulations  that  are  much 
more  severe  than  those  perceived  in  epicritic  sensibility.  This 
form  of  sensibility  is  often  retained  when  epicritic  sensibility 
is  lost,  and  in  the  return  of  sensation  after  disease  the  proto- 
pathic sensibility  reappears  before  the  epicritic  sensibility.  It 
is  tested  for  in  the  same  way  as  epicritic  sensibility,  with  the 
exception  that  the  stimuli  must  be  more  severe;  thus  in  testing 
tactile  sense,  instead  of  barely  touching  the  surface  with  a  camel's- 
hair  brush,  etc.,  the  application  must  be  made  with  more  force. 
In  testing  pain  sense  the  stimulations  are  applied  more  severely, 
and  in  testing  temperature  sense  the  test-tubes  should  contain 
very  hot  and  very  cold  water. 

Deep  Sensibility. — Muscle  Sense. — This  should  be  tested  for 
in  both  upper  and  lower  extremities.  The  patient  closes  his 
eyes,  and  the  examiner  lightly  grasps  a  toe  and  flexes  or  extends 
the  same,  while  the  patient  indicates  the  direction  in  which  the 
movements  are  being  made.  The  same  tests  are  to  be  made  with 
the  ankle-  and  knee-joints,  the  fingers,  the  wrist,  the  elbow,  etc. 

Paresthesias  or  Subjective  Sensations. — Of  these,  numbness, 
tingling,  formication,  a  sense  of  swelling  or  of  smallness,  burning, 
heat  or  cold,  etc.,  may  be  complained  of.  The  distribution  and 
duration  of  these  sensations  should  always  be  noted. 

Tenderness  of  the  nerve-trujiks  on  pressure  is  to  be  examined 
for  by  compressing  the  superficial  nen.^es  between  the  examiner's 
fingers  and  adjacent  bony  structures — the  ulna,  the  back  of  the 
internal  condyle  of  the  humerus,  the  anterior  tibial,  the  back  of 
the  head  of  the  fibula,  the  musculospiral  ner\'e  in  its  groove 
along  the  outer  side  of  the  humerus,  etc.,  are  among  the  ner^'es 
most  easily  tested  for. 


164 


MANUAL   OF   NERVOUS   DISEASES 


SENSORY  FUNCTIONS  1 65 

The  Hysterogenic  Zones. — Pressure  should  be  made  over 
the  ovarian  region,  inframammary  region,  beneath  the  clavicles, 
over  the  apex  of  the  heart,  the  epigastric  region,  etc.  An 
abnormal  sensitiveness  to  even  light  pressure  in  these  regions  is 
frequently  present  in  functional  conditions,  but  also  occurs  in 
diseased  states  of  the  underlying  organs. 

Stereognostic  Sense. — This  form  of  sensation  is  tested  for  by 
having  the  patient  close  his  eyes,  and  then  placing  different 
objects  in  his  hand.  Under  normal  conditions  the  individual  is 
able  to  name  familiar  objects  from  the  various  sensations  im- 
parted to  him  from  the  feel  of  these  objects.  An  inability  to 
recognize  these  objects  is  called  astereognosis. 

Apraxia. — This  is  a  condition  in  which  an  individual,  even  if 
he  is  familiar  with  the  name  of  an  object  and  can  describe  its 
use,  is  unable  to  go  through  the  movements  that  should  accom- 
pany its  use.  This  condition  is  always  serious,  as  it  indicates  an 
extensive  disintegration  of  the  associative  cerebral  tracts. 

Disturbance  of  sensation  may  occur  as  the  result  of  organic  or 
functional  disease:  when  it  is  the  result  of  functional  disease,  the 
distribution  is  such  as  would  correspond  to  cerebral  involvement ; 
when  it  is  due  to  organic  disease,  it  may  be  caused  by  either 
irritation  or  destruction  of  peripheral  nerves,  spinal  cord,  brain- 
stem, or  brain. 

It  is  only  from  a  study  of  the  distribution,  the  character  of 
sensory  disturbances,  and  often  after  a  careful  consideration 
of  other  symptoms,  that  one  is  enabled  to  say  definitely  which 
portion  of  the  central  or  peripheral  nervous  system  is  involved 
(Figs.  90,  01). 

Vasomotor  and  Secretory  Disturbances. — Examination  is 
to  be  made  to  discover  if  abnormalities  of  the  vasomotor  bal- 
ances are  present:  these  are  evidenced  by  cyanosis,  abnormal 
paleness,  abnormal  redness,  rapid  transition  from  paleness  to 
redness  or  vice  versa,  peculiar  purplish  appearance  of  the  skin, 
delayed  return  of  the  normal  color  to  the  skin  after  pressure  or 
irritation,  and  dermatographia. 

Secretory  disturbances  evidence  themselves  in  abnormalities 
of  the  secretions.  They  may  be  either  increased  or  decreased, 
and  this  increase  or  decrease  may  be  localized  or  general.     In 


i66 


MANUAL   OF  NERVOUS  DISEASES 


rare  instances  there  is  a  perversion  of  the  secretions — instead  of 
the  normal  color  and  odor  the  secretions  become  abnormal  in 
color  and  odor. 


f>;     *3<    »]3       . 

^  A  q  ^f^  ^ 


9^ 


Trophic  Disturbances. — ^These  should  be  carefully  examined 
for.  They  may  affect  the  superficial  tissues,  giving  rise  to 
alterations  in  the  appearance  of  the  skin,  falling  out  of  the  hair, 
change  in  the  color  of  the  hair,  falling  out  of  the  teeth,  a  changed 
appearance  of  the  nails,  which  latter  may  become  brittle,  ridged, 
thickened,  etc.    Ulcerations  may  affect  the  skin  and  the  super- 


ELECTRIC   EXAMINATION  1 67 

ficial  tissues,  or  the  trophic  disturbances  may  involve  the  deeper 
structures,  affecting  the  bones,  joints,  muscles,  etc.,  and  giving 
rise  to  such  conditions  as  perforating  ulcers,  Charcot  joints, 
abnormal  brittleness  of  the  bones,  etc. 


ELECTRIC  EXAMINATION 

In  making  an  examination  of  the  muscles  and  nerves  as  to 
their  electric  excitability,  one  must  have  a  faradic  battery,  with 
which  there  should  be  connected  a  resistance  coil  for  increasing 
or  decreasing  the  strength  of  the  current;  a  galvanic  battery, 
which  will  supply  at  least  a  current  up  to  30  milliamperes ;  a 
galvanometer;  an  automatic  interrupter;  two  conducting  wires; 
a  number  of  electrodes,  varying  in  size  from  24  square  inches 
to  a  small  rounded  electrode  about  J  inch  in  diameter,  and  a 
metal  brush. 

In  order  to  make  an  electric  examination  it  is  necessary  to  be 
familiar  with  the  areas  at  which  the  nerves  and  muscles  respond 
most  readily  to  electric  stimulation;  these  areas  correspond  to 
the  positions  at  which  the  motor  or  mixed  nerves  lie  near  the 
surface,  or  the  points  at  which  the  nerves  enter  the  muscles. 
The  accompanying  diagrams  (Fig.  92)  show  the  position  of 
these  points. 

The  nerv^es  that  are  most  readily  accessible  to  electric  stimula- 
tion are  the  facial,  the  median,  the  musculospiral,  the  ulnar, 
the  anterior  crural,  the  sciatic,  and  the  anterior  tibial  nerv^es. 

In  making  the  examination  one  must  be  certain  that  the 
apparatus  is  in  good  working  order.  The  electrodes  are  to  be 
moistened  with  warm  salt  solution,  and  the  patient's  skin  should 
be  moistened  with  the  same  solution.  The  parts  to  be  examined 
are  to  be  placed  in  such  a  position  that  they  can  be  obser\'ed 
well  and  are  easily  accessible.  Furthermore,  they  should  be 
in  such  position  as  to  bring  about  relaxation  of  the  muscles  to 
be  examined. 

In  making  an  examination  one  should  test  the  affected  muscles 
with  the  faradic  and  galvanic  currents,  in  order  to  determine 
if  there  is  increased  or  decreased  response  to  either  the  galvanic 


i68 


MANUAL  OF  NERVOUS   DISEASES 


or  the  faradic  current ;  whether  there  is  a  qualitative  disturbance 
of  the  electric  reaction,  bringing  about  a  partial  or  complete 


^\\«\»^   i 


Fig.  92. — Areas  at  which  the  nerves  and  muscles  respond  most  readily  to 

electric  stimulation. 


reaction  of  degeneration.     In  special  cases  the  myasthenic,  the 
myotonic,  and  the  tetanic  reactions  should  be  tested. 


ELECTRIC   EXAMINATION  1 69 

The  faradic  current  is  transmitted  only  by  ner\^e-fibers ;  the 
galvanic  is  transmitted  by  both  nerve-fibers  and  muscle  tissue. 
It  is  the  inability  of  the  faradic  current  to  be  transmitted  through 
muscle  tissue  in  the  absence  of  nerve-fibers  that  is  responsible 
for  the  Cjualitative  changes  to  electric  stimulation  in  diseased 
conditions. 

In  making  an  examination  with  the  faradic  current  one 
electrode — usually  a  large  one — is  placed  at  some  indifferent 
point  over  the  back,  the  sternum,  etc.;  the  other  electrode, 
which  may  vary  in  size  from  the  smallest  to  one  about  i|  inches 
in  diameter,  is  applied  over  the  nerve  or  the  excitable  area  of 
the  muscle  that  is  to  be  tested.  The  strength  of  the  current  is 
gradually  increased  until  a  muscle  contraction  occurs  or  until 
the  examiner  is  satisfied  that  muscle  contraction  with  this 
current  cannot  be  induced. 

Under  normal  conditions  currents  of  very  moderate  strength 
produce  a  muscle  contraction  that  is  continuous  until  the  current 
is  interrupted,  either  upon  stimulation  of  the  nerv^e  or  of  the 
muscles,  the  response  requiring  slightly  weaker  current  upon 
stimulation  of  the  nerve  than  upon  that  of  the  muscle. 

In  examining  with  the  galvanic  current  one  may  use  a  large 
electrode,  placed  at  some  indifferent  point,  and  a  smaller  elec- 
trode, about  I  inch  in  diameter,  which  is  to  be  placed  over 
either  the  nerve  or  the  muscle  that  is  to  be  tested.  In  some 
cases  it  is  necessary  to  use  two  small  electrodes,  placing  one 
over  each  end  of  the  muscle  under  examination. 

Under  normal  conditions,  when  the  galvanic  current  is  passed 
continuously  through  a  nerve  or  muscle,  no  muscle  contraction 
results,  and  it  is  only  upon  opening  or  closing  the  electric  circuit 
that  the  contraction  occurs.  The  contraction  that  results  upon 
closing  the  circuit  under  these  conditions  is  stronger  than  the 
contraction  that  results  upon  the  opening  of  the  circuit,  and 
the  contraction  occurring  at  the  negative  pole  is  more  marked 
than  the  contraction  at  the  positive  pole. 

In  diseased  conditions  it  is  necessary  to  compare  the  amount 
of  current  required  to  bring  about  contractions  of  muscles 
situated  in  similar  areas  on  the  two  sides  of  the  body,  or  to 
compare  the  amount  of  current  required  in  the  affected  indi\ddual 


lyo  MANUAL   OF  NERVOUS   DISEASES 

with  the  amount  required  in  a  healthy  individual.  Care  must 
always  be  exercised,  however,  to  exclude  local  conditions  that 
may  interfere  with  the  transmission  of  the  current,  such  as 
diseases  of  the  skin,  scars,  etc. 

Simple  decrease  of  electric  excitability  takes  place  in  atrophy 
from  disuse,  in  primary  muscle  affections,  such  as  muscular 
dystrophy,  in  atrophy  of  muscles  following  diseases  of  the  joints, 
and  in  very  mild  inflammatory  conditions  of  the  nerves.  In- 
creased reaction  to  electric  stimulation  is  unusual,  but  is  present 
in  marked  degree  in  tetany. 

Myasthenic  Reaction. — This  reaction  has  been  described  by 
Jolli,  and  occurs  only  in  myasthenia  gravis.  It  is  characterized 
by  the  fact  that  muscles  can  be  stimulated  to  contraction  by  the 
faradic  current,  but  if  the  faradic  car  rent  is  continued  for  some 
time,  the  current  being  interrupted  at  intervals,  there  gradually 
occurs  a  decrease  in  the  force  of  the  muscular  contraction,  until 
finally  the  muscles  cease  to  contract  even  when  the  current  is 
increased  in  strength.  After  a  period  of  rest  the  muscles  will 
again  respond  to  stimulation. 

Myotonic  Reaction. — Faradic  stimulation  of  the  nerves  with 
a  strong  current  causes  tonic  muscular  contractions  that  persist 
after  the  interruption  of  the  current.  Continuous  faradic 
stimulation  sometimes  causes  wave-like  contractions  of  the 
stimulated  muscles;  galvanic  stimulation  of  the  nerves  is  some- 
what diminished.  Direct  galvanic  excitability  of  the  muscles 
is  increased,  contractions  occurring  only  upon  closing  the  current; 
these  contractions  are  characterized  by  the  slowness  with  which 
they  occur,  their  tonic  character,  and  their  persistence. 

Tetanic  Reaction. — Very  weak  currents  produce  muscle  con- 
tractions— this  is  less  constant  to  the  faradic  current  than  to  the 
galvanic.  A  very  weak  galvanic  current  will  produce  contraction 
upon  closing  of  the  circuit  at  the  negative  pole;  a  slight  increase 
of  the  strength  of  the  current  produces  a  tetanic  contraction 
of  the  muscles  at  the  negative  pole. 

In  some  cases  a  tetanic  contraction  occurs  with  a  weak 
current  at  the  positive  pole  upon  interrupting  the  current. 

Reaction  of  Degeneration. — Upon  the  extent  of  the  involve- 
ment of  the  nerves  are  dependent  the  qualitative  changes,  which 


ELECTRIC    EXAMINATION  171 

may  vary  from  slight  alterations  from  the  normal  to  a  complete 
reaction  of  degeneration. 

Complete  reaction  of  degeneration  is  characterized  by  the 
following  symptoms:  (a)  Faradic  stimulation  of  the  affected 
ner\'e  is  not  followed  by  muscular  contraction,  independent  of 
the  strength  of  the  current;  (b)  faradic  stimulation  of  the  muscle 
is  not  followed  by  a  contraction  in  spite  of  the  strength  of  the 
current,  (c)  Galvanic  stimulation  of  the  nerves  is  not  followed 
by  muscle  contractions,  either  upon  opening  or  upon  closing  the 
current,  and  these  are  not  influenced  by  the  strength  of  the 
current.  These  three  symptoms  are  caused  by  the  inability  of 
the  affected  nerve  to  transmit  the  electric  current. 

Upon  galvanic  stimulation  of  the  muscles  the  following  alter- 
ations from  the  normal  take  place:  First,  the  excitability  of  the 
muscle  is  increased;  that  is,  a  more  marked  contraction  is  brought 
about  in  the  affected  muscles  than  in  the  unaffected  muscles 
when  currents  of  equal  strength  are  used,  or  weaker  currents 
cause  the  muscles  to  contract;  second,  there  is  an  alteration  in 
the  way  in  which  the  contraction  occurs — under  these  conditions 
the  contractions  are  slow^  and  w^ave-like;  third,  there  is  a  change 
from  the  normal  in  the  strength  of  the  contraction  to  the  negative 
and  the  positive  pole — under  these  conditions  the  contraction 
occurring  at  the  positive  pole  upon  closing  the  current  is  stronger 
than  the  contraction  that  occurs  at  the  negative  pole  upon 
closing  the  current. 

The  exaggeration  of  the  galvanic  irritability  is  found  only 
in  the  first  stages  of  the  disease  and  gradually  diminishes.  The 
most  constant  symptom  in  this  reaction  is  the  slow,  wave-like 
contraction  of  the  muscle. 

In  some  cases,  instead  of  complete  reaction  of  degeneration 
there  occurs  a  condition  that  is  characterized  by  a  slight  decrease 
of  the  irritability  of  the  nerves.  In  this  condition  faradic 
stimulation  of  the  ner\Ts  is  not  followed  by  muscle  contraction, 
or  very  strong  currents  may  be  followed  by  muscle  contraction — 
faradic  stimulation  of  muscles  is  followed  by  contraction,  stronger 
currents  than  normal  being  used.  Galvanic  stimulation  of  the 
nerA^e  is  generally  not  followed  by  muscle  contraction,  galvanic 
stimulation  of  the  muscles  upon  closing  of  the  current  causing 


172  MANUAL  OF  NERVOUS  DISEASES 

a  slow,  wave-like  contraction  that  may  be  more  marked  at  the 
positive  pole  than  at  the  negative  pole.  There  are  many  stages 
of  variation  of  electric  reaction  between  a  mild  partial  and  a 
complete  reaction  of  degeneration. 

In  making  an  electric  examination  one  should  compare  the 
reaction  obtained  in  a  healthy  muscle  with  that  obtained  in  the 
muscle  under  examination.  The  process  of  degeneration  in  the 
nerves  and  the  muscles  occurs  more  or  less  rapidly  after  the 
onset  of  a  diseased  condition.  The  changes  in  the  electric 
excitability  of  the  muscles  and  nerves  occur  simultaneously 
with  the  degenerative  changes  that  take  place  in  the  nerves  and 
muscles;  consequently,  as  from  a  few  days  to  nearly  two  weeks 
may  elapse  before  the  degenerative  changes  that  have  begun  in 
a  nerve  and  muscle  are  complete,  one  cannot  expect  the  reaction 
of  degeneration  to  occur  before  the  end  of  from  a  few  days  to 
two  weeks.  In  diseased  conditions  in  which  there  is  complete 
atrophy  of  muscle  and  muscle  tissue  is  replaced  by  fibrous  tissue 
formation  all  electric  excitability  is  lost. 

The  reaction  of  degeneration  is  present  in  all  severe  diseases 
of  the  motor  or  mixed  peripheral  nerves  and  in  destructive 
diseases  of  the  anterior  horns  and  anterior  roots.  Very  fre- 
quently muscles  recover  their  functions  before  the  electric 
reactions  have  returned  to  the  normal. 

EXAMINATION   OF   THE   CRANIAL  NERVES 

The  First,  or  Olfactory  Nerve. — This  is  the  special  nerve  of 
the  sense  of  smell,  and  is  tested  in  the  following  manner:  The 
patient  should  close  his  eyes,  and  the  examiner  should  place 
near  the  nostril  such  non-irritating  substances  as  orange-peel, 
cinnamon,  or  a  weak  solution  of  the  extract  of  rose  or  of  lavender. 
Each  nostril  should  be  tested  separately.  As  the  substance  is 
brought  to  the  nose  the  patient  is  to  signify  whether  or  not  he 
recognizes  or  perceives  the  odor.  He  should  also  be  questioned 
as  regards  the  existence  of  hallucinations  of  smell. 

The  Second  or  Optic  Nerve — the  Nerve  of  Vision. — In  testing 
this  nerve  one  should  determine  whether  or  not  the  patient 
sees,  testing  each  eye  separately.     The  patient's  vision  should 


EXAMINATION   OF   THE   CRANIAL   NERVES  173 

be  tested  as  regards  his  ability  to  differentiate  various  colors, 
and  the  field  of  vision  for  white  and  colors  should  be  taken. 

Examination  should  be  made  for  refractive  errors.  In  all 
cases  a  careful  ophthalmoscopic  examination  should  be  made  to 
determine  the  condition  of  the  optic  nerve  and  of  other  structures 
in  the  fundus  of  the  eye. 

The  Third  Nerve,  or  Motor  Oculi;  the  Fourth  Nerve,  or 
Patheticus ;  the  Sixth  Nerve,  or  Abducens. — These  three  nerves 
supply  the  various  muscles,  internal  and  external,  of  the  eye. 
They  are  tested  in  the  following  manner:  The  patient  is  asked  to 
follow  the  movements  of  the  examiner's  finger,  which  is  moved 
outward,  upward,  downw^ard,  inward,  and  then  in  a  circle.  In 
case  weakness,  paralysis,  or  disturbance  exists,  this  will  be 
evidenced  by  the  inability  of  one  or  both  eyes  properly  to  follow 
the  examiner's  finger.  In  making  this  examination  one  must  be 
on  the  alert  to  detect  weakness,  paralysis,  nystagmus,  etc.,  of 
the  muscles  of  one  or  both  eyes.  If  nystagmus  is  present,  the 
variety,  the  direction,  whether  active  or  passive,  must  be  noted. 

Examination  of  the  Pupils  of  the  Eyes. — One  must  observe 
w^hether  the  pupils  are  equal  in  size,  whether  they  are  irregular  in 
outline,  and  their  size.  The  pupillary  reactions  are  tested  for  in  the 
following  way:  The  patient  should  be  examined  m  a  room  that 
is  not  too  well  lighted.  He  must  not  face  the  light,  and  should 
fix  his  gaze  upon  some  object  at  a  distance.  The  exammer 
stands  at  the  side  of  and  slightly  in  front  of  the  patient,  and 
light  from  a  small  hand-lamp  or  some  other  source  is  thrown  into 
the  pupil.  Under  normal  conditions  the  pupil  promptly  becomes 
smaller;  in  abnormal  conditions  the  contraction  of  the  pupil  may 
be  slow  or  may  not  occur  at  all. 

In  testing  for  the  pupillary  reaction  to  accommodation  one 
must  be  able  to  see  the  pupils  distinctly.  The  patient  is  then 
told  to  fix  his  gaze  at  some  distant  point;  he  is  next  directed  to 
look  at  the  point  of  a  pencil  held  in  the  examiner's  hand.  The 
pencil  is  then  gradually  moved  toward  the  patient's  nose, 
when,  as  the  two  eyeballs  converge  toward  the  median  line,  there 
occurs,  under  normal  conditions,  a  contraction  of  the  pupils. 

Argyll  Robertson  pupil  is  one  which  fails  to  react  to  light, 
but  does  react  to  accommodation. 


174  MANUAL   OF   NERVOUS   DISEASES 

Consensual  Reaction. — Here  again  the  examiner  must  be  able 
clearly  to  see  the  two  pupils.  Upon  throwing  more  light  into 
one  pupil,  under  normal  conditions,  the  opposite  pupil  decreases 
in  size,  and  upon  diminishing  the  amount  of  light  entering  one 
pupil,  the  opposite  pupil  increases  in  size. 

Sympathetic  reaction  of  the  pupil  is  tested  for  by  slightly  irri- 
tating the  skin  of  the  neck  in  front  of  the  ear  below  the  angle  of 
the  jaw.  When  this  is  done  under  normal  conditions,  a  dilata- 
tion of  the  pupils  occurs. 

The  Fifth  or  Trifacial  Nerve. — The  tests  applied  to  ascertain 
the  condition  of  this  nerve  include  sensory,  motor,  the  special 
sense  of  taste,  and  reflex  activity.  In  testing  for  the  sensory 
quality  of  this  nerve  the  examiner  should  apply  the  ordinary 
tests  for  sensation;  that  is,  tactile,  pain,  and  temperature  sense 
to  the  skin  and  to  the  mucous  membranes  of  the  face,  side  of 
the  head,  nose,  mouth,  etc.,  in  the  region  supplied  by  this  nerve. 
If  disturbance  exists,  it  should  be  noted  whether  the  same  is 
limited  in  distribution  to  one  or  more  of  the  principal  branches. 

The  Motor  Functions. — ^The  examiner  directs  the  patient  to 
close  the  jaws  tightly  and  to  feel  with  the  fingers  whether  or  not 
the  masseters  contract  on  one  or  both  sides.  He  is  then  directed 
to  go  through  the  movements  of  chewing,  in  order  to  learn 
whether  or  not  the  pterygoids  are  performing  their  functions. 

To  test  for  the  special  sense  supplied  by  this  nerve  one  must 
examine  the  anterior  two-thirds  of  the  tongue  for  taste;  this  is 
best  done  by  explaining  to  the  patient  what  is  desired,  and 
warning  him  not  to  swallow  the  testing  fluids  until  he  has 
signified  whether  or  not  he  has  perceived  the  taste.  The  fluids 
to  be  used  should  consist  of  solutions  of  salt,  vinegar,  and  sugar. 
Let  the  patient  open  the  mouth  fairly  wide,  and  protrude  the 
tongue  slightly;  then  touch  one  side  of  the  anterior  two-thirds 
of  the  tongue  with  one  of  the  solutions,  and  let  him  signify 
whether  it  is  salty,  sour,  or  sweet.  Both  sides  of  the  anterior 
two- thirds  of  the  tongue  should  be  tested. 

The  reflex  activity  of  this  nerve  is  to  be  tested  for  by  the  jaw- 
jerk  and  conjunctival  reflex. 

The  Seventh  or  Facial  Nerve. — ^This  nerve  is  to  be  tested  by 
observing  whether  the  patient  can  wrinkle  the  forehead  close  to 


EXAMINATION   OF   THE   CRANIAL   NERVES  1 75 

the  eyes,  draw  over  the  corner  of  the  mouth,  smile,  whistle,  pout, 
etc.  Weakness  or  paralysis  of  the  muscles  supplied  by  this  nerve 
is  indicated  by  inability  to  perform  these  acts  equally  well  on 
both  sides. 

The  Eighth  or  Auditory  Nerve. — Auditory  Portion. — In  making 
this  test  the  individual's  hearing  must  be  tested  with  a  tuning- 
fork,  watch,  etc.,  both  for  air  and  for  bone  conduction. 

Vestibular  Portion. — It  is  also  important  to  test  the  patient's 
equilibrium,  for  in  diseased  conditions  of  this  nerve  rapid  changes 
in  position  are  often  attended  by  a  loss  of  equilibrium,  and  in 
some  disorders  vertigo  is  more  or  less  constantly  present.  The 
patient  should  always  be  questioned  as  to  the  presence  of 
tinnitus  aurium  and  hallucinations. 

Caloric  Reaction. — When  one  ear  of  a  normal  person  is  syringed 
out  with  cold  water,  the  head  being  held  upright,  a  horizontal 
and  rotatory  nystagmus  toward  the  other  ear  occurs;  when  hot 
water  is  used,  the  nystagmus  is  directed  toward  the  syringed  ear. 
In  cases  of  destruction  of  the  labyrinth  of  the  vestibular  nerve  on 
the  side  under  examination  this  reaction  does  not  occur. 

In  special  cases  the  Barany  tests  should  be  carried  out  in 
detail. 

The  Ninth  or  Glossopharyngeal  Nerve. — ^To  test  this  nerve 
one  should  apply  the  same  tests  for  taste  that  are  recommended 
in  testing  the  fifth  nerve  to  the  posterior  third  of  the  tongue. 

The  Tenth  or  Pneumogastric  Nerve. — In  testing  this  nerve 
one  should  test  the  pharyngeal  reflex  and  the  ability  of  the 
patient  to  swallow.  He  should  be  given  dry  and  liquid  food, 
and  it  should  be  observed  whether  this  is  promptly  passed  into 
the  esophagus  or  if  there  is  a  tendency  for  it  to  regurgitate 
through  the  nose. 

Examination  should  be  made  of  the  larynx  to  discover  whether 
or  not  any  of  the  laryngeal  muscles  are  weak  or  paralyzed.  The 
character  of  the  voice  is  to  be  noticed.  It  must  be  remembered 
that  this  nerve  is  intimately  associated  with  the  action  of  the 
heart,  the  lungs,  and  the  stomach. 

The  Eleventh  or  Spinal  Accessory  Nerve. — This  test  is  made 
by  having  the  patient  turn  the  head  from  side  to  side,  flex  and 
extend  the  head  against  resistance,  and  elevate  the  shoulders. 


176  MANUAL   OF  NERVOUS   DISEASES 

The  state  of  contraction  and  the  muscular  power  of  the  sterno- 
cleidomastoid muscle  and  the  upper  portion  of  the  trapezius 
muscle  are  to  be  noted. 

The  Twelfth  or  Hypoglossal  Nerve. — This  nerve  is  tested  by 
examining  the  state  of  nutrition  of  the  tongue,  and  whether  there 
are  any  abnormalities  of  movement,  and  the  ability  of  the  patient 
to  move  the  tongue  freely  and  to  protrude  the  same  from  the 
mouth.  Weakness  or  paralysis  will  evidence  itself  by  inter- 
ference with  the  ability  to  move  a  part  or  the  entire  tongue. 

SPINAL   PUNCTURE 

The  withdrawal  of  cerebrospinal  fluid  by  inserting  a  hollow 
needle  into  the  spinal  canal  is  done  for  diagnostic  and  therapeutic 
purposes. 

The  needle  may  be  inserted  into  the  spinal  canal  in  almost 
any  region  of  the  spina,!  column,  but  in  some  regions  this  pro- 
cedure is  very  difficult,  whereas  in  others  it  is  comparatively 
simple  (Fig.  93). 

In  making  a  lumbar  puncture  the  patient  may  be  in  the 
recumbent  position  lying  on  his  side,  or  sitting  up.  In  order 
that  this  procedure  may  be  readily  carried  out  it  is  necessary 
that  the  spinal  column  be  flexed  as  much  as  possible,  its  con- 
vexity being  directed  backward,  thus  separating  the  lamina  of  the 
vertebrae.     Lumbar  puncture  was  first  done  by  Quincke  in  1891. 

The  needle,  which  should  be  about  five  or  six  inches  long, 
must  be  sharp,  and  contain  a  stilet;  it  should  not  be  too  flexible. 
It  should  be  introduced  between  the  second  and  third  or  the 
third  and  fourth  lumbar  vertebrae.  The  needle  should  be  boiled 
before  using,  and  a  sterile  dish  for  the  reception  of  the  spinal 
fluid  should  be  placed  conveniently  at  hand.  The  patient's  back, 
from  the  midline  to  about  one  and  one-half  inches  on  each  side, 
from  the  ninth  or  tenth  dorsal  vertebra  to  the  sacrum,  should 
be  rendered  surgically  clean  and  aseptic  by  painting  the  area 
with  iodin  or  by  thorough  scrubbing. 

An  imaginary  line  is  to  be  projected  across  the  back  at  the 
level  of  the  crests  of  the  iliac  bones.  The  needle  is  to  be  in- 
serted at  a  point  on  this  imaginary  line  one-half  inch  on  either 


SPINAL   PUNCTURE 


177 


side  of  the  midline.  It  is  directed  slightly  inward  and  slightly 
upward.  After  going  through  the  skin  and  muscles  the  stilet 
should  be  withdrawn,  and  the  needle  gently  pushed  forward. 
As  soon  as  it  pierces  the  dura  there  will  be  a  flow  of  cerebrospinal 
fluid. 

At  times  there  may  be  difiSculty  in  entering  the  spinal  canal, 
as  when  the  needle  comes  into  contact  with  the  laminae  of  the 
vertebrae.     Under  these  conditions  the  needle  should  be  with- 


Fig.  93. — Spinal  puncture. 

drawn  a  short  distance,  and  the  point  either  elevated  or  de- 
pressed until  it  slips  between  the  two  laminae. 

In  some  instances  where  the  needle  is  inserted  too  far  from  the 
midline,  or  is  directed  at  an  improper  angle,  it  does  not  enter  the 
canal,  but  traverses  a  course  forward  in  the  large  muscles  of  the 
back.  In  this  case  it  is  better  to  withdraw  the  needle  entirely 
and  make  a  fresh  attempt.  If  the  patient  is  very  restless  and 
resists  the  effort,  or  if  marked  opisthotonos  is  present,  it  may  be 
impossible  to  insert  the  needle  in  the  lumbar  region;  in  these 
12 


178  MANUAL   OF  NERVOUS   DISEASES 

cases  I  have  frequently  found  it  possible  to  perform  a  spinal 
puncture  in  the  cervical  region,  between  the  sixth  and  seventh 
cervical  vertebrae,  or  in  the  dorsal  region.  One  should  find  the 
lower  border  of  the  spinous  process  of  the  sixth  cervical  ver- 
tebra, and  then,  after  the  proper  aseptic  precautions  have  been 
taken,  introduce  the  needle  near  the  midline,  below  the  spinous 
process,  directing  it  slightly  upward. 

When  the  needle  is  introduced  into  the  spinal  canal,  under  nor- 
mal conditions  the  spinal  fluid  flows  out  clear  at  the  rate  of  about 
40  to  60  drops  a  minute.  In  those  conditions  in  which  there  is 
increased  intracranial  pressure  or  when  an  increased  amount  of 
cerebrospinal  fluid  is  present,  it  may  flow  out  in  a  continuous 
stream.  In  cases  in  which  intracranial  pressure  is  decreased 
and  the  blood-pressure  is  very  low,  where  there  is  evidence  of 
shock,  etc.,  the  cerebrospinal  fluid  flows  more  slowly  than 
normal.  If  the  needle  has  been  introdu(^ed  too  far  into  the 
spinal  canal,  there  usually  occurs  a  puncture  of  some  of  the  small 
veins,  causing  bloody  cerebrospinal  fluid  to  appear. 

In  pathologic  conditions  the  cerebrospinal  fluid  may  be 
perfectly  clear,  or  it  may  be  turbid,  bloody,  and  purulent.  If 
the  cerbrospinal  fluid  will  not  run,  the  patient's  head  should  be 
elevated,  and  he  should  be  instructed  to  take  a  few  deep  breaths, 
which  will  usually  cause  a  small  quantity  of  fluid  to  appear. 

Where  it  is  desired  to  measure  the  pressure  under  which  the 
cerebrospinal  fluid  flows,  any  one  of  several  forms  of  apparatus 
may  be  attached  to  the  needle. 

A  normal  spinal  fluid  is  clear,  of  a  very  pale  straw  color,  and 
contains  a  few  cells  and  about  0.2  per  cent,  of  albumin.  An 
increase  of  albumin  in  the  cells  and  the  presence  of  microorgan- 
isms indicate  a  pathologic  condition  of  the  brain  and  membranes. 

CRANIOCEREBRAL   TOPOGRAPHY 

It  is  important  for  surgeons  and  physicians  to  be  familiar 
with  the  relation  of  the  fissures  and  convolutions  of  the  brain 
to  the  surface  of  the  skull. 

The  frontal  bones  cover  the  greater  part  of  the  frontal  lobes. 
The  base  of  the  frontal  convolutions  lies  beneath  the  anterior 


CRANIOCEREBRAL   TOPOGRAPHY 


179 


part  of  the  parietal  bones.  The  precentral  and  postcentral  con- 
volutions, the  parietal  lobes,  and  the  anterior  part  of  the  occipi- 
tal lobes  are  situated  beneath  the  parietal  bones.  The  parietal 
eminence  practically  corresponds  to  the  upper  part  of  the 
marginal  gyrus.  The  temporal  bones  cover  the  greater  part  of 
the  temporal  lobes.  The  upper  part  of  the  occipital  bone  covers 
the  occipital  lobes,  and  inferior  to  the  occipital  eminence  it 
covers  the  cerebellum  (Fig.  94). 

Another  important  aid  is  to  be  able  to  map  out,  on  the  surface 
of  the  skull,  the  fissure  of  Rolando  (Fig.  94).     Methods  have 


Fig.  94. 


-Relations  of  the  principal  fissures  of  the  cerebrum  to  the  outer 
surface  of  the  scalp  (Reid). 


been  devised  by  investigators  who  agree  that  the  simplest 
method  by  which  this  fissure  may  be  located  is  to  measure  the 
distance  from  the  root  of  the  nose  to  the  external  occipital 
protuberance;  this  distance  is  then  bisected,  and  about  2  cm. 
posterior  to  this  point  is  the  upper  end  of  the  fissure  of  Rolando. 
From  this  point  the  fissure  runs  downward  and  forT\'ard,  forming 
an  angle  of  about  67  degrees  with  the  sagittal  line.  The  lower 
third  of  the  fissure  of  Rolando  is  somewhat  more  vertical  than 
the  upper  two- thirds. 

Another  method  for  projecting  the  fissure  of  Rolando  on  the 
surface  of  the  skull  is  described  by  Reid  and  Bergmann.     This  is 


l8o  MANUAL   OF   NERVOUS   DISEASES 

as  follows:  At  the  anterior  margin  of  the  external  auditory 
meatus  a  perpendicular  line  is  drawn  from  the  sagittal  line, 
which  is  a  line  from  the  root  of  the  nose  to  the  external  occipital 
protuberance.  About  two  inches  behind  this  first  perpendicular 
line  a  second  perpendicular  line  is  drawn ;  this  passes  across  the 
posterior  margin  of  the  mastoid  process.  At  the  point  at  which 
this  second  vertical  line  meets  the  sagittal  line  is  the  upper  end 


Fig.  95- — Showing  fissure  of  Rolando  outlined  on  the  surface  of  head. 

of  the  fissure  of  Rolando,  the  lower  end  being  found  on  the  ante- 
rior vertical  line,  about  two  inches  above  the  external  auditory 
meatus  (Fig.  94). 

If  one  can  determine  the  location  of  the  fissure  of  Rolando 
and  remember  that,  approximately,  the  various  lobes  of  the 
brain  lie  beneath  the  cranial  bones  of  a  similar  name,  it  is 
comparatively  easy  to  determine  the  relation  of  the  important 
cerebral  centers  to  the  surface  of  the  skull. 


DISEASES   OF  THE  PERIPHERAL   NERVES 

The  peripheral  nerves,  owing  to  their  long  course,  are  fre- 
quently injured  and  exposed  to  the  action  of  harmful  substances 
that  may  cause  inflammatory^  changes. 

Injury  leads,  according  to  its  severity,  to  more  or  less  complete 
interruption  of  the  conductivity  of  the  affected  nerve.  It  varies 
from  a  slight  irritation  of  the  nerve  that  may  be  either  transient 
or  continued,  to  an  injury  severe  enough  to  entirely  interrupt 
the  conductivity  of  the  nerve. 

Injur}'  is  brought  about  by  pressure,  by  section,  or  by  traction. 
It  may  be  extensive  or  limited,  and  may  be  of  momentary 
duration  or  continue  over  a  long  time.  Inflammation  of  the 
nerves  may  arise  from  the  perineuriumi,  and  be  limited  practi- 
cally to  this  structure  (perineuritis) ;  it  may  be  situated  mainly 
in  the  interstitial  tissue  {interstitial  neuritis),  or  within  the  nerve- 
fibers  {parenchymatous  neuritis). 

The  first  two  forms  correspond  to  the  t}^e  of  a  true  inflam- 
matory process.  A  sharp  distinction  cannot,  however,  be  made 
between  different  forms,  as  inflammation  arising  from  the  peri- 
neurium and  endoneurium  usually  involves  the  parench}Tna. 
The  inflammation  may  be  localized  or  general,  ascending  or 
descending,  multiple  or  migratorv\  After  injury  or  inflamma- 
tion of  a  nerv^e,  depending  upon  the  extent  and  severity,  changes 
take  place  in  the  portions  of  the  nerve  distal  to  the  involved 
area  and  also  to  a  slight  extent  in  that  portion  of  the  nerve 
proximal  to  the  affected  area.  This  process  is  called  the  process 
of  degeneration,  and  according  to  the  severity  of  the  lesion  do 
we  have  partial  or  complete  degeneration.  This  process  was 
first  described  by  A.  V.  Waller.  It  is  a  change  brought  about  in 
the  part  of  the  nerve  distal  to  the  lesion,  caused  by  the  inability 
of  the  cell  to  supply  nourishment  to  this  portion. 

Within  from  two  to  four  days  after  the  injury  the  myelin  of  the 
nerv^e  becomes  disintegrated  throughout  its  entire  extent.     The 

i8i 


l82  MANUAL   OF   NERVOUS   DISEASES 

breaking  up  of  the  myelin  is  followed  by  disintegration  of  the 
axis-cylinder,  and  the  nuclei  of  the  sheath  of  Schwann  increase 
in  size  and  number.  The  products  of  this  disintegration  are 
gradually  absorbed,  and  the  nerve  is  ultimately  replaced  by  the 
fibrous  tissue  cord.  The  intramuscular  ramifications  of  the 
nerve  and  the  end-plates  also  degenerate. 

This  process  does  not  take  place  under  all  conditions,  but 
only  when  the  lesion  is  extensive  and  severe,  and  when  regenera- 
tion is  interfered  with.  In  those  cases  in  which  the  cause  is 
removed  or  in  which  the  extent  and  severity  of  the  injury  are  not 
so  great,  or  when  the  severed  ends  of  the  nerves  are  in  good 
apposition,  the  process  of  regeneration  takes  place.  Generally, 
when  regeneration  takes  place  it  is  due  to  the  outgrowth  of  new 
neurofibrillae  from  the  proximal  end  of  the  affected  nerve  into 
the  remains  of  the  degenerated  nerve.  There  certainly  are 
some  undoubted  cases  on  record  that  seem  to  prove  that  it  is 
also  possible  for  the  nerves  to  resume  their  functions  so  rapidly 
that  there  must  be  another  more  rapid  process;  if  this  is  the 
case,  it  occurs  only  in  very  few  instances.  Under  favorable 
conditions  the  nerve-fibers  begin  to  regenerate  within  about 
two  weeks  after  the  pathologic  process  has  been  removed,  and 
under  favorable  conditions  regeneration  takes  place  at  the  rate 
of  about  one-half  inch  a  week. 

If  regeneration  is  prevented,  connective- tissue  formation  oc- 
curs in  the  stump  of  the  affected  nerve,  and  there  is  an  outgrowth 
of  neurofibrillse,  which  curl  up  upon  themselves  and  eventually 
form  a  small  painful  tumor. 

If  the  pathologic  process  is  only  very  slight  and  the  axis- 
cylinder  is  not  affected,  the  functions,  as  a  rule,  are  rapidly 
restored,  since  degeneration  does  not  take  place. 

The  causes  of  diseases  of  nerves  may  be  grouped  under  the 
following  heads:  Trauma,  which  may  be  gradual  or  sudden, 
slight  or  severe,  inflicted  externally  or  internally,  continued  or 
transitory;  toxins,  which  may  be  exogenous  or  endogenous, 
acute  or  chronic;  chemical  agents,  climatic  conditions,  metabolic 
diseases,  hemic  conditions,  vascular  disease;  or  it  may  be  the 
result  of  disease  in  the  neighboring  tissue. 

Symptoms  of  disease  of  the  nerves  depend  upon  the  extent 


DISEASES    OF    THE   PERIPHERAL    NERVES  1 83 

and  character  of  the  pathologic  condition,  the  character  of  the 
nerve  or  nerv^es  affected,  and  the  distribution  of  the  affected 
nerve  or  nerves. 

If  a  mixed  nerve  is  affected,  we  may  have  sensor\^,  motor, 
vasomotor,  and  trophic  symptoms;  if  the  motor  nerv^es  are 
involved,  we  have  symptoms  limited  to  disturbance  of  function 
and  nourishment  of  the  motor  apparatus,  and  perhaps,  also, 
vasomotor  symptoms. 

In  the  case  of  the  sensory  nerves,  we  have  disturbance  or 
perversion  of  sensation,  with  or  without  vasomotor  and  trophic 
symptoms. 

Motor  symptoms — either  weakness  or  paralysis;  in  these 
cases  the  muscle  tone  is  decreased,  and  the  paralysis  is  of  the 
flaccid  t}^e.  The  tendon  reflex  of  the  affected  muscles  is  either 
diminished  or  lost.  The  paralysis  is  followed  rapidly  by  atrophy, 
except  in  those  cases  in  which  the  weakness  is  limited  and  the 
involvement  is  very  slight. 

The  normal  electric  reactions  are  also  disturbed.  The  use  of 
the  electric  current,  galvanic  and  faradic,  plays  a  very  important 
part  in  the  diagnosis  and  treatment  of  diseases  of  the  peripheral 
ner\^es.  The  faradic  or  interrupted  current  exerts  its  effect  upon 
the  muscle-fibers  by  being  conducted  through  these  by  nerve- 
fibers.  In  order  to  secure  the  effect  of  the  current  it  is  necessary 
that  intact  or  practically  healthy  nerve-fibers  be  present.  The 
galvanic  or  continuous  current  is  transmitted  both  by  ner^^e- 
fibers  and  by  muscle-fibers,  and  in  diseased  conditions,  where  the 
nerve-fiber  is  affected,  the  muscle-fibers  readily  convey  this 
current.  Under  normal  conditions,  when  we  apply  the  faradic 
current  to  a  ner\'e-fiber  or  a  muscle,  if  the  current  is  sufi&ciently 
strong,  it  produces  tonic  muscular  contraction.  If  a  strong 
galvanic  current  is  applied  to  a  nerv^e-fiber  or  muscle,  it  merely 
produces  muscle  contraction  upon  the  closing  or  opening  of  the 
circuit,  the  flow  of  current  through  the  muscle  having  no  visible 
effect.  The  muscle  contraction  is  sharp  and  quick,  and  is  more 
marked  at  the  negative  than  at  the  positive  pole. 

In  diseased  conditions  of  the  peripheral  nerves  there  are  dis- 
turbances of  the  muscle  reaction  to  the  electric  current.  This 
reaction  is  known  as  the  reaction  of  degeneration,  and  is  present 


184  MANUAL   OF   NERVOUS   DISEASES 

whenever  there  is  an  abolition  of  the  conductivity  of  the  nerve, 
lasting  until  the  nerve  either  regenerates  or  all  the  muscle-fibers 
have  atrophied  and  have  been  replaced  by  fibrous  tissue. 

In  the  reaction  of  degeneration  we  have  the  following  re- 
sponses to  the  current:  The  application  of  the  faradic  current  to 
the  nerve  or  muscle  produces  absolutely  no  muscle  response, 
no  matter  how  strong  this  current  may  be.  On  applying  the 
galvanic  current  we  get  a  muscle  contraction  that  is  stronger  at 
the  positive  pole  than  at  the  negative,  and  stronger  upon  closing 
the  circuit  than  upon  opening  it.  The  muscle  contraction, 
instead  of  being  sharp  and  prompt,  is  slow  and  wave-like,  and 
the  galvanic  stimulation  through  the  nerve  is  lost.  Partial 
reaction  of  degeneration  occurs  when  a  very  much  stronger 
faradic  current  than  normal  is  required  to  bring  about  muscle 
contraction,  whereas  in  direct  galvanic  stimulation  the  slug- 
gishness of  contraction  becomes  evident. 

Sensory  Symptoms. — Paresthesia. — Slight  involvement  of  the 
nerve  may  give  rise  merely  to  symptoms  of  irritation,  tingling, 
and  numbness.  If  the  lesion  is  relieved,  there  is  a  rapid  dis- 
appearance of  these  symptoms.  A  slight  general  numbness  of 
all  the  fingers  of  both  hands,  and  even  of  the  hands  and  wrists 
as  well,  occasionally  occurs,  and  may  be  of  short  duration 
or  may  become  permanent.  This  is  seen  chiefly  in  those 
who  use  the  hands  continuously  for  hours.  It  has  been  called 
by  Dana  acroparesthesia,  and  may  be  attended  by  a  sense  of 
weakness. 

Pain. — This  may  be  local,  or  may  follow  the  distribution  of 
the  affected  nerve  or  nerves.  It  is  particularly  apt  to  be  present, 
although  it  varies  in  severity,  whenever  there  is  irritation  of  the 
proximal  end  of  the  affected  nerve.  It  usually  occurs  after  inju- 
ries in  which  the  nerve  is  torn  or  is  exposed,  or  in  those  cases  in 
which  local  inflammation  exists.  In  painful  conditions  the  pain 
is  not  only  felt  locally,  but  is  generally  referred  to  the  peripheral 
distribution  of  the  nerve.  Pain  does  not  always  remain  limited 
to  the  distribution  of  the  affected  nerves,  but  may  extend  to 
neighboring  structures. 

Tenderness. — ^This  condition  frequently  accompanies  painful 
states,  but  may  be  present  even  if  the  pain  is  not  a  prominent 


DISEASES    OF    THE   PERIPHERAL   NERVES  1 85 

symptom.  It  may  be  limited  to  the  nerve- trunk  or  may  be 
diffuse. 

Disturbances  in  the  Conduction  of  Sensation. — There  may  be  a 
decreased  rapidity  of  the  conduction  of  sensory  stimuli,  resulting 
in  delayed  and  consequent  slowness  of  perception,  or  there  may 
be  difhculty  in  the  transmission  of  the  stimuli,  whereby  the 
acuteness  is  decreased  and  an  obtundation  or  anesthesia  results. 

After  disease  or  injury  of  the  nerves  the  individual  may  rapidly 
regain  the  protopathic  sense,  whereas  disturbance  of  the  epi- 
critic  sensibility  persists  for  considerable  time.  In  lesions  of 
a  single  nerve  affections  of  sensibility  are  usually  limited  to 
an  area  much  smaller  than  would  be  expected  from  the  anatomic 
distribution  of  the  nerve. 

Vasomotor,  Secretory,  and  Trophic  Disorders. — ^These  dis- 
orders frequently  occur  in  diseases  or  injuries  of  the  peripheral 
nerves.  They  consist  of  redness,  with  local  rise  of  temperature, 
which  may  be  succeeded  later  by  cyanosis  and  subnormal  tem- 
perature. There  is  increase,  decrease,  or  absence  of  the  per- 
spiration. The  skin  is  smooth  and  glossy,  very  thin  and  tender, 
and  there  are  superficial  ulcerations,  herpes,  and  blisters.  The 
growth  of  the  hair  and  nails  may  be  affected.  \\Tien  extensive 
destruction  of  the  nerves  close  to  the  spinal  column  occurs  in 
childhood  the  bones  may  cease  to  grow. 

The  prominent  symptoms  of  disease  of  the  peripheral  nerve, 
depending  upon  the  severity  and  the  extent  of  the  disease,  are 
flaccid  motor  weakness  or  paralysis,  loss  or  decrease  of  the  tendon 
reflexes,  muscular  atrophy,  partial  or  complete  reaction  of  degen- 
eration, paresthesia,  tenderness,  pain,  anesthesia,  and  vasomotor, 
secretory,  and  trophic  disturbances. 

Unless  the  disease  of  the  nerve  is  due  to  some  sudden  over- 
whelming condition,  the  first  indications  consist  usually  of  pares- 
thesia and  hyperesthesia  in  the  area  of  distribution  of  the 
affected  nerve.  There  m.ay  also  be  evidence  of  slight  muscular 
irritability,  such  as  tonic  contractions,  fibrillary  tremors,  or 
increased  electric  excitabiUty. 

Course  and  Prognosis. — The  onset  may  be  acute,  subacute, 
or  chronic.  The  acute  cases  are  generally  secondar}^  to  trauma. 
Subacute  and  chronic  cases  are  slower  in  their  onset. 


1 86  MANUAL   OF  NERVOUS   DISEASES 

In  most  cases  of  peripheral  nerve  affections  the  prognosis  as 
regards  recovery  is  good.  Wherever  the  causative  agent  can 
be  removed,  recovery  should  take  place,  except  under  the 
following  conditions :  If  there  is  a  physical  impediment  to  nerve 
regeneration,  such  as  callus,  fibrous  tissue,  scar  formation,  or 
the  absence  of  nerve  tissue,  or  if  the  nerves  are  affected  very 
close  to  their  points  of  emergence  from  the  spinal  column. 

The  duration  of  the  disease  depends  upon  the  severity,  extent 
of  involvement,  and  the  possibility  of  removal  of  the  cause.  In 
those  cases  in  which  the  cause  can  be  entirely  removed  and  the 
electric  reactions  are  normal,  recovery  should  take  place  within 
six  weeks.  In  those  cases  in  which  the  causative  agent  can  be 
removed  and  there  is  partial  reaction  of  degeneration,  recovery 
should  take  place  within  from  four  to  six  months.  When  the 
cause  can  be  removed  and  there  is  complete  reaction  of  degenera- 
tion, recovery  should  take  place  in  from  six  months  to  two  years. 
The  prognosis  is,  of  course,  dependent  on  the  ability  to  remove 
the  cause,  the  conditions  under  which  treatment  is  carried  out, 
and  on  the  treatment  itself. 

Treatment. — ^The  prime  requisite  for  successful  treatment  is 
to  discover  and  to  remove  the  cause.  If  the  condition  is  due  to 
injury,  it  is  necessary  to  institute  proper  local  treatment.  If 
one  has  reason  to  believe  that  the  nerve  has  been  severed  and 
that  the  ends  are  displaced,  it  is  my  opinion  that  one  is  justified 
in  making  a  surgical  exploration  to  bring  the  ends  of  the  severed 
nerve  into  apposition,  suturing  them  if  necessary.  In  all 
recent  acute  cases  absolute  rest  for  the  affected  part  is  the  first 
indication,  every  movement  and  muscle  contraction  being  likely 
to  excite  inflammatory  processes.  All  pressure  or  traction  upon 
the  affected  nerve  should  be  avoided.  The  treatment  is  given 
in  detail  in  the  discussion  of  the  special  forms  of  neuritis. 

SPECIAL    FORMS    OF    TRAUMATIC    AND    INFLAM- 
MATORY  DISEASES    OF   THE    SPINAL   NERVES 

Paralysis  of  the  Phrenic  Nerve. — Paralysis  of  the  phrenic 
nerve  is  very  uncommon  because  of  the  protected  position  of 
the  nerve.     It  may  occasionally,   however,   be  produced  by 


TRAUMATIC   AND    INFLAMMATORY    DISEASES  187 

compression  between  the  clavicle  and  the  spinal  column,  or  as 
the  result  of  compression  by  tumors  in  the  neck  or  throax.  The 
nerve  may  be  involved  in  toxic  or  infectious  conditions.  Diph- 
theric paralysis  frequently  involves  this  nerve. 

Paralysis  of  one  side  of  the  diaphragm  gives  rise  to  no  symp- 
toms, and  can  be  diagnosed  only  as  the  result  of  very  careful 
physical  examination. 

The  symptoms  of  bilateral  paralysis  of  the  phrenic  nerve  are 
those  of  paralysis  of  the  diaphragm.  The  latter  does  not  con- 
tract on  inspiration,  and  there  is  consequently  no  protrusion  of 
the  epigastrium.  On  expiration  the  abdomen  protrudes  and 
the  liver  descends.  Dyspnea  is  not  always  present,  but  usually 
occurs  upon  movement  and  may  be  very  severe. 

The  prognosis  is  good  in  the  rheumatic  and  diphtheric  forms. 
In  multiple  neuritis  and  under  other  conditions  involvement  of 
the  phrenic  nerve  has  an  unfavorable  prognosis. 

Treatment. — This  consists  in  removing  the  cause  and  treating 
the  general  condition.  Every  effort  should  be  rriade  to  prevent 
overexertion  and  to  avoid  pulmonary  complications.  Internally, 
strychnin  in  proper  doses  should  be  given  three  or  four  times  a 
day. 

Cervicobrachial  NeuritiSo — Under  certain  conditions  the 
nerves  comprising  the  cervical  and  the  brachial  plexuses  may 
all  be  involved,  and  under  other  conditions  the  disease  process 
may  involve  only  a  small  portion  of  either  one  of  these  plexuses 
(Fig.  96). 

Etiology. — Extensive  involvement  of  these  two  plexuses  rarely 
occurs.  The  condition  is  most  prone  to  affect  individuals  after 
the  thirtieth  year.  La  grippe  is  the  most  frequent  of  the 
causative  agents,  may  also  follow  infectious  diseases,  exten- 
sive injuries,  tumors,  inflammatory  conditions  of  the  neck, 
tubercular  and  arthritic  conditions  of  the  cervical  vertebrae. 

The  symptoms  of  extensive  involvement  usually  consist  of  pain 
extending  through  the  occipital  region,  shoulder,  arm,  and  fore- 
arm; weakness  or  paralysis  of  the  deep  muscles  of  the  neck, 
shoulder,  arm,  and  forearm;  decrease  or  loss  of  the  triceps, 
biceps,  and  periosteoradial  reflexes;  partial  or  complete  reaction 
of  degeneration  of  the  affected  muscles;  sensory  disturbances, 


i88 


MANUAL  OF  NERVOUS  DISEASES 


varying  from  paresthesia  to  anesthesia  of  the  neck,  shoulder, 
arm,  forearm,  and  perhaps  the  hand.  Except  in  very  severe 
involvement  of  these  two  plexuses,  pain  is  the  most  prominent 
symptom. 

N.hypo^hssas //    ^^^^^ 


fo  m-rectus capitis laferajts 


N.occipitaJis  minor    rr\^ 
Pamus  descendens  n  hypoglosii-. 
Naui-icularis  ma^nus 
A/.  cu7anevs  colli 


^ma  hypoglossi — 

i.  ,      .,  \7oTn. I eifafor scapulae 
5capulae\  fg  „„_  rhomboidei 

Nn.  supraclaviculars 
Nphrenicus- 

N.  supra  scapularis 
N.  Subscapulan's 
fi/.Subclavius 

N.axHiaris 
fj.  subscapularis 

Al.Pioraco- 

aorsah's 

MradiaJis 

torn.  Cora  CO 
brachialis 

Hmusculo 
cuTaneus  ' 
Nnlhoracaks 
a/iTen'ores 

N.medianus 
N.ulnetris 


N.culaneus 
antibrachii  medialis 

A?  cutaneus  brach'n'- 
fne  dial  is  „ 

/V/r.  inTercoslobrachiales 


to  m. rectus  capitis  anterior 
tomlongus  Capitis. 

0  m.  longus  Capitis 
■to  m.  interlrwisversarius. 


tomm.longi  capitis  et Colli 
to  m.  inttrtransversarlus. 
to  m.  levator.jcapulae- 

10  m.lpngus  colli- 

to  m.interTransversarius- 

To  m,  scalenus  medius. 


Cs 

—tom.longus  colli 
lo  mm.  scalenus  ant  et- 
I  nfertrans  verjarius . 

to  m.  scalenus  medius  ■ 

iomlongas  colli 

fo  mm.  scalenus  ant  et 

interlransversarius . 

torn,  scalenus  medius. 


to  m.  scalenus  anterior, 
to  m.  intertransversanus 
to  rn.  Scalenus  medius 
tJ -thoracal is  longus 

To  m./nlertransversarius 
to  m,  scalenus  medius 


h.1 
i\l.  intercostal  is  I 


—N.intercostalis  11 
Fig.  96. — Cervicobrachial  plexus  (after  P.  Eisler). 


The  course  of  this  condition  is  usually  somewhat  prolonged, 
lasting  from  three  to  eighteen  months. 

The  diagnosis  is  made  from  the  history  of  the  onset  and  the 
distribution  of  the  symptoms.     The  most  important  diagnostic 


TRAUMATIC    AND    INFLAMMATORY   DISEASES  1 89 

aid  is  the  discovery  of  the  cause;  this  often  requires  a  very  care- 
ful physical  examination  and  the  use  of  ic-ray. 

The  prognosis  depends  upon  the  severity  of  the  case  and  the 
ability  to  remove  the  cause. 

Treatment.— ^^vaowQ  the  cause.  Put  the  parts  at  rest  for 
a  short  time,  remembering  that  if  the  shoulder-joint  is  immobil- 
ized for  too  long  a  period  trophic  changes  may  take  place  that 
will  later  result  in  limitation  of  movement.  My  experience  has 
been  that  the  best  results  are  obtained  if  passive  motion  of  the 
shoulder-  and  elbow-joints  is  practised  throughout  the  illness, 
care  being  taken  not  to  allow  the  patient  to  participate  in  these 
movements.  Warm  applications  and  counterirritation  along 
the  side  of  the  neck  and  over  the  trapezius  muscle  are  useful 
in  cutting  short  the  acuteness  of  the  condition  and  in  relieving 
pain.  Pyramidon,  phenacetin,  salicylate  of  soda,  codein  sul- 
phate, or  morphin  may  be  used  for  the  relief  of  pain.  The 
positive  pole  of  the  continuous  galvanic  current  applied  over  the 
affected  area  with  the  negative  pole  at  some  indifferent  point 
of  the  body  may  also  give  relief.  As  soon  as  the  condition  of 
the  parts  will  permit,  gentle  massage  is  to  be  practised.  The 
affected  muscles  are  to  be  treated  electrically,  using  that  cur- 
rent which  will  produce  muscle  contraction.  The  patient's 
general  nutrition  is  to  be  maintained,  and  as  soon  as  the 
acute  stage  has  passed  he  should  be  given  strychnin  sulphate 
internally  in  proper  doses  three  or  four  times  a  day.  In  addi- 
tion to  this  I  have  also  found  small  doses  of  potassium  iodid 
to  be  of  benefit. 

The  disease  may  be  limited  to  the  cervical  plexus,  and  in  this 
case  the  symptoms  w^ould  be  limited  to  pain  in  the  back  of  the 
neck,  over  the  occipital  region,  disinclination  to  move  the  head 
because  of  the  pain,  weakness  or  paralysis  of  the  deep  neck 
muscles,  and  occasionally  trophic  disturbances,  as  evidenced 
by  the  falling  out  of  the  hair  and  herpetic  eruptions. 

Disease  of  the  Brachial  Plexus. — ^This  may  be  caused  by 
injuries  to  the  neck,  as  from  a  blow,  stabbing  or  cutting  wounds, 
a  fall  on  the  elbow,  dislocation  of  the  humerus,  fracture  of  the 
shoulder-joint  or  clavicle,  pressure  on  the  brachial  plexus  between 
the  clavicle  and  the  first  rib  or  accessory  cervical  rib,  traction, 


I  go 


MANUAL   OF   NERVOUS   DISEASES 


etc.,  tumors  pressing  on  the  brachial  plexus,  rheumatic,  toxic, 
or  infectious  agents  (Fig.  97). 


Fig.  97. — Extensive  injury  to  brachial  plexus,  caused  by  tree  falling  on 
shoulder,  causing  complete  atrophic  paralysis,  with  marked  sensory  dis- 
turbance of  entire  right  upper  extremity. 


The  plexus  may  be  completely  or  partially  involved,  the 
symptoms  depending  upon  the  position  and  extent  of  the  in- 
volvement. 

One  of  the  commoner  forms  of  partial  paralysis  is  that  known 
as   Erb^s   combined   shoulder-arm   paralysis.    This   affects    the 


TRAUMATIC    AND    INFLAMMATORY    DISEASES  191 

deltoid,  biceps,  brachialis  anticus,  and  supinator  longus  muscles, 
and  sometimes  also  the  supinator  brevis,  infraspinatus,  and 
subscapularis.  This  form  of  paralysis  arises  from  a  lesion  of 
the  fifth  and  sLxth  cervical  roots  or  the  upper  primary  cord  of 
the  plexus.  It  usually  is  produced  by  traction,  tearing,  pres- 
sure between  the  clavicle  and  first  rib,  pressure  upon  the  nerves 
as  from  carrying  weights  upon  the  shoulder ;  or  it  may  be  second- 
ary to  some  toxic  condition  or'  the  result  of  compression  by 
tumors,  etc.  The  symptoms  that  result  consist  of  inability  to 
abduct  the  arm  or  to  flex  it  at  the  elbow-joint ;  pronation  of  the 
forearm  and  hand,  with  the  sup ina ting  power  limited,  and  some 
inward  rotation  of  the  arm.  The  arm  hangs  at  the  side, 
pronated  and  rotated  inward.  The  weakness  or  paralysis  is 
atrophic,  wdth  complete  or  partial  reaction  of  degeneration,  loss 
of  tendon  reflex  of  the  supinator  and  biceps,  with  retention  of 
the  triceps  jerk.  Pain  may  be  present.  Sensory  disturbances, 
if  they  occur,  are  usually  limited  and  disappear  rapidly.  In 
some  cases  there  may  be  persistent  anesthesia  in  the  cutaneous 
area  innervated  by  the  circumflex  and  musculocutaneous  nerves; 
that  is,  in  the  small  area  over  the  shoulder  and  on  the  outer 
side  of  the  upper  arm,  perhaps  on  the  external  surface  of  the 
forearm. 

Paralysis  of  the  Inferior  Plexus. —  Klumpke^s  paralysis  is  due 
to  an  affection  of  the  eight  cervical  and  first  dorsal  roots  or  the 
part  of  the  plexus  which  they  form.  It  may  be  caused  by  tumors, 
surgical  operations,  gun-shot  wounds,  traction,  or  may  be 
secondary  to  infectious  conditions,  etc.  The  s}Tnptoms  are 
paralysis  of  the  small  muscles  of  the  hand  and  of  some  of  those 
of  the  forearm,  especially  the  flexors  (Fig.  98).  Sensory  dis- 
turbances are  usually  present  in  the  area  supplied  by  the  ulnar 
nerve  and  sometimes  part  of  the  distribution  of  the  median 
nerve. 

The  entire  brachial  plexus  may  be  involved,  but  this  is  un- 
common. The  involvement  may  at  first  be  general,  but  may 
later  become  limited  to  the  area  of  certain  nerv^es.  The  circum- 
flex and  musculospiral  nerves  are  most  often  involved,  probably 
by  lesion  of  the  posterior  cord  of  the  plexus.  Sensory  s\Tnptoms 
are  usually  present,  but  vary  greatly  in  extent,  and  no  agreement 


192 


MANUAL  OF  NERVOUS  DISEASES 


necessarily  exists  between  the  motor  and  the  sensory  involve- 
ment. 

Cervical  ribs,  by  compressing  the  plexus,  may  produce  symp- 
toms of  irritation  and  paralysis. 

The  diagnosis  of  disease  of  the  brachial  plexus,  either  in  part 
or  in  its  entirety,  is  made  from  the  presence  of  weakness  or 
paralysis  of  a  flaccid  char^-cter,  sensory,  vasomotor,  and  trophic 


Fig.  98. — Injury  of  lower  brachial  plexus,  Klumpke's  paralysis  resulting  from 

gun-shot  wound. 


disturbances,  disturbances  of  the  tendon  reflexes  and  electric 
reaction  occurring  in  the  distribution,  which  can  be  referred 
only  to  cervical  roots,  primary  trunks  of  the  brachial  plexus,  or 
the  plexus  itself. 

The  prognosis  depends  entirely  upon  the  possibility  of  com- 
pletely removing  the  cause,  and  also  upon  the  extent  and  severity 
of  the  involvement  of  the  affected  nerves. 


TRAUMATIC  AND   INFLAMMATORY   DISEASES  1 93 

In  those  cases  due  to  traction,  if  at  all  severe,  due  to  cutting 
injuries  or  secondary  to  dislocation  of  the  shoulder,  the  outlook 
for  complete  recovery  is  not  good.  As  a  rule,  some  atrophic 
paralysis  remains,  regeneration  being  very  slow. 

The  treatment  of  diseases  of  the  brachial  plexus  resolves  itself 
into  the  treatment  and  removal  of  the  cause,  the  relief  of  pain, 
and  surgical  intervention  if  there  is  severance  of  the  nerve. 

For  the  relief  of  pain,  aspirin,  phenacetin,  codein,  morphin, 
etc.,  in  proper  doses,  may  be  given.  In  many  cases  it  may  not 
be  necessary  to  resort  to  drugs,  for  the  pain  can  be  relieved 
by  hot  applications,  rest,  and  the  application  of  the  positive 
pole  of  the  galvanic  current  to  the  painful  area  for  from  three  to 
five  minutes.  Every  effort  should  be  made  to  render  the  patient 
comfortable. 

Trophic  disturbances  in  the  distribution  of  the  affected  nerves 
can  often  be  prevented  by  protecting  the  parts  from  pressure 
or  injury  and  by  strict  attention  to  cleanliness.  The  nourish- 
ment of  the  muscles  and  skin  may  be  partially  maintained  by 
passive  exercise  and  gentle  massage  with  cocoa-butter.  As 
soon  as  the  acute  inflammatory  stage  of  the  nerves  has  sub- 
sided, and  with  ver}^  few  exceptions  immediately  in  traumatic 
cases,  the  use  of  electricity  is  advisable.  The  faradic  or  in- 
terrupted galvanic  current  is  to  be  used.  If  the  faradic  current 
is  used,  one  pole  should  be  placed  proximal  to  the  lesion  and  the 
other  pole  applied  over  the  distribution  of  the  affected  nerve  or 
nerv^es.  In  those  cases  in  which  the  faradic  current  fails  to 
excite  muscle  contraction  the  interrupted  galvanic  current  will 
be  required.  One  pole  is  placed  over  the  muscles  and  the  other 
on  the  affected  ner\^e,  or  both  poles  may  be  placed  over  the 
muscles,  using  that  pole  over  the  muscle  that  will  give  the  best 
muscle  contraction  with  the  least  current.  The  current  should 
be  automatically  interrupted  from  60  to  120  times  a  minute. 
The  faradic  current  should  be  applied  for  about  five  or  ten 
minutes  over  the  entire  affected  area.  The  galvanic  stimulation 
should  be  applied  to  each  one  of  the  affected  muscles  for  a  few 
seconds,  after  which  they  should  be  allowed  to  rest  and  then 
again  be  stimulated,  giving  each  muscle  about  one  to  two 
minutes'  exercise. 

13 


194  MANUAL   OF  NERVOUS   DISEASES 

Surgical  treatment  is  demanded  in  traumatic  cases  that  show 
no  tendency  to  recovery  after  three  or  four  months'  general 
treatment. 

Brachial  neuritis  due  to  exposure  to  cold  is  a  common  disease. 
Pain  localized  in  the  plexus  and  radiating  outward  is  at  times 
extremely  severe.  Soon  after  the  onset  there  are  numbness  and 
tingling,  followed  by  pain  which  is  more  or  less  constant,  and 
finally  by  weakness  and  paralysis.  The  onset  of  the  disease 
covers  a  period  of  several  days,  and  within  ten  days  the  muscles 
may  show  distinct  atrophy  and  the  reaction  of  regeneration. 

Trophic  disturbances  of  the  skin,  such  as  herpes  or  eruptions, 
thin,  glossy  skin,  interference  with  the  growth  of  the  nails,  and 
abnormalities  of  the  secretions  are  common.  The  skin  is  usually 
hypersensitive  and  covered  with  perspiration.  These  cases 
generally  last  for  from  four  to  twelve  months.  The  prognosis 
is  good,  most  cases  making  a  complete  recovery. 

The  treatment  consists  of  absolute  rest,  hot  applications,  and 
counterirritation  over  the  affected  nerve-trunks,  the  positive 
pole  of  a  weak  continuous  galvanic  current  being  applied  to  the 
painful  region  for  several  minutes  every  day.  Analgesics  should  be 
given  for  the  relief  of  the  pain,  and  sodium  salicylate,  aspirin,  etc., 
in  proper  doses',  be  frequently  administered  throughout  the  day. 
The  bowels  should  be  kept  weh  open,  and  later,  when  there  is 
less  pain,  the  use  of  the  interrupted  electric  current  and  massage 
to  the  affected  muscles  are  indicated.  General  nutrition  should 
be  maintained  and  as  soon  as  the  acute  stage  has  passed, 
strychnin  and  other  tonics  should  be  prescribed. 

Obstetric  Paralysis,  or  Birth  Palsy  of  Duchenne. — ^Under 
this  head  we  include  only  paralysis  of  the  upper  extremi- 
ties occurring  in  the  child  (Figs.  99,  100).  It  is  caused  by 
compression  or  traction  exerted  against  the  brachial  plexus 
either  by  a  finger  or  hook,  or  by  the  clavicle  when  the  effort 
is  made  to  deliver  a  delayed  shoulder.  The  condition  may  be 
caused  by  the  pressure  of  forceps  if  the  blades  reach  the  cervical 
region.  It  occurs  also  in  those  cases  in  which  the  arm  has  be- 
come extended  and  the  effort  is  made  to  bring  the  arm  down;  in 
breech  presentation  in  which  there  is  difficulty  in  delivering  the 
head  and  traction  is  made  with  pressure  against  the  shoulder. 


TRAUMATIC   AND    INFLAMMATORY    DISEASES  1 95 

An  obstetric  paralysis  is  seldom  seen  to  occur  in  deliveries 
effected  without  artificial  assistance.  The  commonest  type  of 
obstetric  palsy  is  due  to  an  involvement  of  the  fifth  and  sixth 
cervical  roots,  occasioning  weakness  or  paralysis  of  the  deltoid, 
biceps,  brachialis  anticus,  supinator  longus,  etc.  The  arm  is 
rotated  inward,  the  hand  pronated,  and  the  forearm  extended. 
Rarely  sensory  disturbances  occur.     In  a  few  cases,  usually  the 


Fig.  99. — Position  of  arm  and  hand  in  peripheral  type  of  birth  palsy. 

effect  of  violence,  the  whole  plexus  may  be  involved.  In  such 
cases  there  are  frequently  fracture  of  the  humerus,  paralysis 
of  the  entire  arm,  and  marked  sensory  disturbances. 

Prognosis. — Obstetric  paralysis  is  very  seldom  bilateral,  and 
the  prognosis  is  usually  favorable.  In  many  cases  the  paralysis 
disappears  within  a  few  weeks,  whereas  in  others  it  may  exist 
for  several  months.     In  nearly  all  cases  there  remains  some 


196 


MANUAL   OF   NERVOUS   DISEASES 


weakness  which  disappears  only  after  years.     In  a  few  cases 
there  is  no  improvement  or  only  partial  recovery. 

Treatment. — As  soon  as  the  condition  is  noticed,  and  if  there 
is  no  surgical  contra-indication,  such  as  a  fractured  humerus,  the 
unaffected  arm  should  be  fastened  to  the  body  for  a  part  of  each 


Fig.  100. — it-Ray  of  forearm  in  same  case  of  obstetric  paralysis,  showing  the 
retarded  development  of  the  bones  of  the  forearm. 


day,  so  as  to  encourage  the  use  of  the  affected  arm.  The  arm 
should  be  gently  massaged  daily.  Deformity  is  to  be  avoided  by 
giving  proper  support  to  the  arm  and  hand.  Electric  treat- 
ment should  be  commenced  early,  using  the  current  that  will 
cause  muscle  contraction.  Later  suitable  gymnastic  exercises 
may  help  many  of  these  cases.     If  there  is  no  tendency  to 


TRAUMATIC   AND   INFLAMMATORY    DISEASES  1 97 

recovery,  surgical  measures  should  be  instituted  after  the 
fourth  year. 

Paralysis  Due  to  Disease  of  the  Long  Thoracic  Nerve. — The 
long  thoracic  nerve  may  be  directly  injured  in  the  supraclavicular 
fossa  or  in  the  axilla  following  injuries  to  the  shoulder,  by  carry- 
ing weights  on  the  shoulder,  etc.  It  affects  men  more  frequently 
than  women.     It  may  also  occur  after  diphtheria  or  typhoid. 

The  symptoms  of  disease  of  this  nerve  are  those  of  paralysis 
of  the  serratus  magnus  muscle;  that  is,  interference  in  the  power 
of  raising  the  arm  above  the  horizontal  plane,  the  scapula  stand- 
ing away  from  the  chest.  The  prognosis  depends  upon  the 
cause. 

Paralysis  of  the  Circumflex  Nerves. — This  is  usually  caused 
by  a  blow  or  fall  upon  the  shoulder,  compression  of  the  nerve, 
rheumatic  and  infectious  conditions. 

The  symptoms  consist  of  pain  and  tenderness  over  the  shoulder, 
paralysis  with  atrophy  of  the  deltoid  muscle,  which  prevents 
abduction  of  the  arm,  relaxation  of  the  ligaments  of  the  shoulder- 
joint,  and  a  small  area  of  anesthesia  over  the  shoulder-joint. 
This  condition  must  be  distinguished  from  a  rheumatic  or 
arthritic  condition  of  the  shoulder- joint  and  also  from  disease 
of  the  deltoid  muscle  itself. 

Paralysis  of  the  Suprascapular  Nerve. — Isolated  paralysis 
of  the  suprascapular  nerve  is  rare.  It  may  occur  after  dis- 
location of  the  humerus  or  from  falls  upon  the  shoulder  or  hand, 
causing  contusion  of  the  shoulder.  The  symptoms  are  paralysis 
and  atrophy  of  the  supra-  and  infraspuiatus  muscles.  This 
results  in  some  interference  with  the  rotation  of  the  humerus 
and  with  the  maintenance  of  the  head  of  the  humerus  in  close 
apposition  to  the  articular  surface  of  the  scapula. 

Paralysis  of  the  Musculospiral  Nerve. — ^The  musculospiral  is 
the  most  frequently  paralyzed  of  all  the  nerves  of  the  extremities. 
This  is  due  chiefly  to  its  exposed  course  and  superficial  position. 
It  is  very  easily  compressed,  resting,  as  it  does,  directly  on  the 
bone.  In  the  great  majority  of  cases  the  paralysis  is  the  result 
of  injury  or  simple  pressure  during  sleep,  either  from  the  head 
resting  on  the  arm  or  the  arm  being  pressed  against  something 
hard.     It  occurs  with  especial  frequency  in  alcoholics,  and  may 


igS  MANUAL   OF   NERVOUS   DISEASES 

follow  violent  action  of  the  muscles.  The  nerve  may  be  injured 
in  fracture  of  the  humerus ;  only  very  rarely  is  the  condition  due 
to  rheumatic  influences.  It  may  follow  hypodermic  injections 
in  the  neighborhood  of  the  nerve. 

The  symptoms  are  wrist-drop,  with  pronation  of  the  hand, 
due  to  paralysis  of  the  supinators,  the  extensors  of  the  wrist  and 
hand,  etc.  The  hand  is  usually  flexed  at  the  wrist- joint;  the 
fingers  are  flexed,  and  the  thumb  is  in  the  position  of  apposition. 
The  hand  and  the  proximal  phalanges  of  the  fingers  cannot  be 
extended,  whereas  extension  of  the  other  phalanges  is  not 
affected.  The  grasp  of  the  hand  is  markedly  weakened,  owing 
to  the  abnormal  position  of  the  hand  and  fingers.  Some  weak- 
ness of  the  power  of  flexion  of  the  elbow  frequently  exists. 

Paralysis  of  the  supinator  longus  muscle  can  readily  be  dem- 
onstrated when  the  forearm  is  in  a  position  midway  between 
pronation  and  supination ;  forcible  flexion  against  resistance  does 
not  cause  this  muscle  to  become  prominent.  The  triceps  is 
rarely  involved  except  when  the  nerve  is  affected  in  the  axilla, 
as  in  dislocation  of  the  humerus  or  in  crutch  paralysis. 

Sensory  disturbances  are  very  uncommon,  and  occur  only  in 
most  severe  cases.  The  electric  reaction  depends  upon  the 
severity  of  the  case,  there  being  many  mild  cases  that  make  a 
rapid  recovery  and  show  no  electric  disturbances.  The  amount 
of  atrophy  also  depends  upon  the  severity  of  the  disease.  The 
prognosis  is  usually  very  good.  Recovery  takes  place  in  from 
a  few  weeks  to  several  months. 

Treatment. — ^The  cause  is  to  be  treated  and  removed.  De- 
formity is  to  be  prevented  by  properly  supporting  the  hand. 
Rarely  are  analgesics  necessary.  The  muscles  of  the  hand  and 
arm  are  to  be  massaged  daily,  and  passive  and  active  exercise 
is  to  be  employed.  Electric  stimulation  of  muscles  and  nerves 
is  useful,  the  current  that  will  cause  muscle  contractions  being 
employed.  The  patient's  general  condition  should  be  treated, 
and  if  no  contra-indication  exists,  strychnin  in  proper  doses 
should  be  given.  In  traumatic  cases,  if  improvement  does  not 
occur  within  from  eight  to  twelve  wxeks,  operative  procedures 
are  indicated. 

Paralysis   of  the   Median  Nerve. — Owing   to  its  protected 


TRAUMATIC   AND    INFLAMMATORY    DISEASES  1 99 

position  isolated  paralysis  of  the  median  nerve  is  an  uncommon 
occurrence,  and  is  usually  traumatic  in  origin.  The  nerve  may 
be  affected  along  with  other  brachial  nerves  in  diseases  or  in- 
juries of  the  brachial  plexus.  It  may  become  paralyzed  as  the 
result  of  the  use  of  an  Esmarch  bandage  or  following  a  blow  or 
cut  in  the  upper  arm,  at  the  elbow,  in  its  course  through  the 
forearm,  and  near  the  wTist- joint.  It  may  also  be  afTected  in  the 
occupation  pareses,  in  ironers,  locksmiths,  milkers,  cigar-makers, 
dentists,  etc.  Puerperal  neuritis  sometimes  involves  the  median 
nerve.  The  median  nerve  supplies  the  pronators,  the  flexors 
of  the  fingers,  the  muscles  that  abduct,  flex,  and  appose  the 
thumb,  and  the  two  radial  lumbricales.  If  the  nerve  is  affected 
above  the  wrist-joint,  the  paralysis  is  confined  to  the  small 
muscles  of  the  hand.  If  the  ner\'e  is  affected  higher  up,  there 
is  an  inability  to  pronate  the  hand  and  to  flex  the  fingers  firmly, 
and  the  thumb  cannot  be  abducted  or  apposed  to  the  tips  of  the 
fingers. 

Sensory  disturbances  are  usually  present,  and  consist  of 
anesthesia  of  the  thumb,  first  and  second  finger,  and  part  of  the 
palmar  surface  of  the  hand;  anesthesia  of  the  terminal  phalanges 
of  the  first  and  second  fingers  posteriorly,  and  sometimes  anes- 
thesia involves  the  radial  half  of  the  ring  finger.  There  is  usu- 
ally some  atrophy  of  the  muscles  supplied  by  this  nerve. 

The  electric  reactions  are  disturbed  in  proportion  to  the  in- 
volvement of  the  nervx.  Vasomotor  and  trophic  disturbances 
occur  ver\^  frequently  in  affections  of  this  nerv^e. 

The  course  and  prognosis  depend  upon  the  severity  and  the 
cause. 

The  treatment  is  that  usually  given  for  diseases  of  the  periph- 
eral nerve. 

Paralysis  of  the  Ulnar  Nerve. — ^This  nerv^e  is  very  frequently 
injured,  as  it  is  exposed  at  the  elbow  and  in  the  forearm.  It 
may  also  be  injured  along  with  other  ner^-es  of  the  brachial 
plexus.  Fracture  or  callus  formation,  disease  of  the  elbow- 
joint,  pressure,  violent  flexion  of  the  forearm,  prolonged  and  con- 
stant use  of  the  muscles  supplied  by  the  ulna,  acute  infectious 
diseases,  the  puerperal  state,  syphilitic  conditions,  and  exposure 
to  wet  and  cold  may  cause  paralysis  of  this  nerve. 


200  MANUAL   OF   NERVOUS  DISEASES 

The  ulnar  nerve  supplies  the  ulnar  flexor  of  the  wrist,  the 
deep  flexors  of  the  last  three  fingers,  the  adductors  of  the  thumb, 
the  muscles  of  the  hypothenar  eminence,  the  interossei,  and  the 
last  two  lumbricales. 

The  symptoms  of  ulnar  nerve  involvement  are  paralysis  of  the 
intrinsic  muscles  of  the  hand,  bringing  about  impairment  in  the 
use  of  the  thumb  and  fingers,  atrophy  of  the  muscles  forming 
the  thenar  and  hypothenar  eminence,  and  the  interossei,  giving 
to  the  hand  a  peculiar  appearance.  There  is  flatness  of  the 
thenar  and  hypothenar  eminence,  the  bones  and  long  tendons 
of  the  fingers  stand  out  beneath  the  skin,  and  the  little  and 
ring  fingers  are  flexed  at  the  second  and  third  phalanges, 
with  extension  of  the  first  phalanges. 

Abduction  and  adduction  of  the  fingers  are  completely  abol- 
ished. Sensory  symptoms  are  usually  present,  and  depend- 
ing upon  the  severity  of  involvement  of  the  nerve  do  we  have 
paresthesia,  pain,  hyperesthesia,  or  anesthesia.  These  dis- 
turbances may  all  be  present,  or  there  may  be  only  anesthesia, 
which  is  usually  limited  to  the  inner  half  of  the  hand  and  little 
finger  and  one-half  of  the  ring  finger.  There  may  be  sensations 
of  cold  or  heat,  vasomotor  and  trophic  disturbances  are  quite 
common. 

The  course  and  prognosis  are  dependent  upon  the  cause 
and  extent  of  the  disease,  the  prognosis  usually  being  very 
good. 

The  treatment  is  that  usually  applied  in  diseases  of  the  per- 
ipheral nerves. 

Neuritis  of  the  Intercostal  Nerves. — This  is  a  very  rare  con- 
dition. It  may  develop  in  association  with  herpes,  malaria, 
typhoid,  gout,  diabetes,  alcoholism,  and  perhaps  exposure.  The 
symptoms  are  pain,  tenderness,  and  sensory  disturbances  in  the 
distribution  of  the  affected  nerve,  with  atrophy  and  paralysis 
of  the  muscles  supplied  by  that  nerve.  One  should  always 
bear  in  mind  that  symptoms  that  may  be  referred  to  disease  of 
the  intercostal  nerves  occur  much  more  frequently  in  spinal 
cord  conditions. 

Diseases  of  the  Nerves  of  the  Lower  Extremities.— The 
lumbar  and  sacral  plexuses  are  much  less  frequently  affected 


TRAUMATIC  AND   INFLAMMATORY    DISEASES  201 

than  the  brachial,  and  the  nerves  of  the  legs  are  not  so  often 
paralyzed  as  are  the  nerves  of  the  arm. 

Diseases  of  the  Nerves  of  the  Lumbar  Plexus. — The  lumbar 
plexus  may  be  affected  by  tumors  or  abscesses  in  the  abdomen 
or  by  diseases  of  the  spine.  It  may  also  be  injured  in  operations 
performed  for  the  relief  of  abdominal  conditions.  The  nerves 
of  the  lumbar  plexus  may  be  independently  involved  as  the 
result  of  trauma,  chronic  intoxication,  infectious  diseases,  etc. 
The  symptoms  are  usually  limited  to  an  area  supplied  by  the 
individual  nerves  (Fig.  loi). 

The  anterior  crural  is  the  branch  of  the  lumbar  plexus  most 
frequently  involved.  The  symptoms  of  involvement  of  this 
nerve  are  weakness  or  paralysis  of  the  extensors  of  the  leg, 
atrophy  of  these  muscles,  loss  of  the  knee-reflex,  pain  and  ten- 
derness, paresthesia,  and  sometimes  a  limited  area  of  anesthesia 
on  the  anterior  and  internal  surface  of  the  thigh,  in  its  lower 
two  thirds,  on  the  inner  surface  of  the  leg  and  ankle,  and  the 
inner  margin  of  the  foot.  There  is  partial  or  complete  reaction 
of  degeneration.  If  the  nerve  is  injured  high  in  the  plexus,  there 
is  also  paralysis  of  the  muscles  that  flex  the  thigh  on  the  trunk. 

The  obturator  nerve  may  also  be  affected  as  the  result  of 
pressure  in  difficult  labor,  pelvic  tumors,  and  in  obturator 
hernia.  The  symptoms  are  paralysis  of  the  adductors  of  the 
thigh  and  sensory  disorders  of  the  inner  aspect  of  the  thigh  in 
its  upper  third. 

Neuritis  of  the  External  Cutaneous  Nerve. — ^This  condition  is 
also  known  as  meralgia  paraesthetica  and  Bernhardt's  disease, 
and  is  caused  by  pressure,  overstrain  of  the  legs,  infectious 
diseases,  gout,  etc.  It  occurs  more  frequently  in  men.  It  is 
characterized  by  paresthesia  and  pain  along  the  outer  side  of  the 
thigh.  There  is  usually  a  small  area  of  diminished  sensation  of 
the  external  surface  of  the  thigh  at  its  inferior  part.  Standing 
and  walking  tend  to  intensify  the  symptoms. 

The  course  of  this  condition  is  generally  prolonged.  The 
treatment  is  that  which  is  usually  applied  in  neuritis,  special 
caution  being  exercised  against  standing  or  walking. 

Neuritis  of  the  Sacral  Plexus. — This  affection  is  very  un- 
common, and  is  due  to  pressure  or  injury  of  the  plexus  during 


202  MANUAL   OF   NERVOUS   DISEASES 

difficult  labor,  this  being  the  form  of  obstetric  paralysis  that 


Tibial  nerve 

Muse,  branch  for 
long  head  oj 
biceps  and 
semilendinosus  >' 


Lateral  ciitan 
eoits  branch 
Iliohypogastric 
nerve 


Lat.  cutaneous  branch  of 

iliohypogastric  nerve 
CcnUojemoral  nerve — ' 
llio-inguinal  nerve-— 

Muscular  branches.'^/: 
to  the  iliopsoasJlJk 

External  spermatic  nerve.' 
Lat.  jemoral  cut.  nerve 
Lumbo-inguinal  nerve-''     • 


Femoral  nerve - 

Access,  obtur.  nerve 


Common 

peroneal 
nerve 
Inferior  gluteal  nerve 


Lumbar 
plexus 


Sacral ' 
plexus- 


Pudendal 
plexus 


Coccygeal 
plexus 


Posterior  femoral  cutatieous  nerve 

Medial  infer,  cluneal  nerve 

Perineal  nerve-\-dors.  nerve  of  penis       I  \i  \^i  A 

Infer,  hemorrhoidal  nerves  '/  \L^ 

S.MWSC.  branches  to  levator  ani  and  cocoygeus  Anococcygeal  nerves 

Fig.  I o I. —Lumbosacral  plexus  (after  P.  Eisler). 

affects  the  mother.     It  may  also  be  due  to  tumors  in  the  pelvis 
or  to  diseased  conditions  of  the  sacrum,  sacro-iliac  disease,  etc. 


TRAUMATIC   AND    INFLAMMATORY  DISEASES  203 

The  symptoms  of  a  neuritis  of  the  sacral  plexus  may  come  on 
gradually  or  suddenly,  depending  upon  the  cause.  There  are 
usually  paresthesia  and  pain  in  the  back  of  the  thigh  and  down 
the  leg.  There  may  be  a  flexor  spasm  of  the  muscles  of  the  leg. 
If  this  condition  is  more  severe,  paralysis  of  the  muscles  of  the 
leg  below  the  knee  occurs,  and  there  are  also  disturbances  of 
sensation  down  the  back  of  the  thigh  and  around  the  outer  side 
of  the  leg  and  foot.  In  milder  affections  the  symptoms  disappear 
w^ithin  a  few  weeks;  in  severer  affections  the  symptoms  may 
require  several  months  to  clear  up.  This  condition  must  be 
differentiated  from  diseased  conditions  of  the  low^er  part  of  the 
spinal  cord:  in  spinal  cord  affections  the  symptoms  are  usually 
bilateral,  with  disturbances  of  the  control  of  the  bladder  and 
rectum;  in  neuritis  of  the  sacral  plexus  the  symptoms  are  gen- 
erally unilateral,  and  there  is  no  disturbance  in  the  control  of 
the  rectum  and  bladder. 

The  prognosis  depends  upon  the  cause,  and  as  this  is  most 
commonly  difficult  labor,  the  prognosis  is  good,  recovery  taking 
place  in  from  a  few  weeks  to  several  months.  The  treatment  is 
that  which  is  usually  applied  in  disease  of  the  peripheral  nerve. 

Neuritis  of  the  Sciatic  Nerve. — ^A  true  neuritis  of  the  sciatic 
nerve  is  a  somewhat  uncommon  condition,  although  many  of 
the  so-called  sciatic  neuralgias  are  true  neuritic  conditions. 
Neuritis  of  the  sciatic  nerve  may  be  caused  by  injury,  pressure 
in  prolonged  or  difficult  labor  or  during  operations  for  the  at- 
tempted reduction  of  congenitally  dislocated  hip-joint;  or  it  may 
be  secondary  to  infectious  diseases  and  intoxications,  la  grippe 
being  a  particularly  frequent  predisposing  cause.  It  often 
occurs  in  gouty  and  anemic  conditions. 

The  symptoms  are  pain  in  the  distribution  of  the  nervx  and 
tenderness  along  the  entire  course  of  the  nerve.  All  movements 
of  the  legs  are  painful,  and  there  is  weakness  or  paralysis  of  the 
muscles  below  the  knee,  with  atrophy  and  the  reaction  of 
degeneration.  Vasomotor  and  trophic  disturbances  are  fre- 
quently present.  There  may  be  areas  of  anesthesia  along  the 
outer  side  of  the  leg  and  foot.  The  condition  is  apt  to  run  a  slow 
course,  lasting  at  times  for  many  months. 

Treatment. — Keep  the  leg  and  thigh  at  absolute  rest,  and 


204  MANUAL  OF  NERVOUS  DISEASES 

apply  counterirritation  along  the  course  of  the  sciatic  nerve. 
Warm  applications  often  give  relief;  it  is  advisable  to  change 
the  position  of  the  affected  leg  frequently.  These  patients 
usually  do  better  if  they  are  kept  in  bed.  Careful  examination 
should  be  made  to  discover  the  cause,  and  this  should,  if  possible, 
be  removed  or  treated.  Pain  is  often  a  very  distressing  symp- 
tom, and  efforts  should  be  made  to  give  the  patient  relief.  The 
positive  pole  of  the  galvanic  current  applied  at  the  upper  end 
of  the  nerve  and  the  negative  pole  upon  the  back  may  prove 
helpful.  Puncture  of  the  nerve  with  needles  and  the  injection 
into  the  nerve  of  cocain  or  of  normal  salt  solution  are  also  used 
to  give  relief. 

Analgesics,  such  as  aspirin,  phenacetin,  codein,  morphin,  etc., 
are  generally  required.  Gentle  massage  may  be  used  if  it  does 
not  cause  too  severe  pain.  The  use  of  the  electric  current  and 
the  administration  of  strychnin  internally  are  to  be  begun  as 
soon  as  the  patient's  condition  allows. 

Neuritis  of  the  External  Popliteal  Nerve. — ^The  external 
popliteal  nerve  is  affected  by  the  same  conditions  that  may  in- 
volve the  sciatic  nerve.  In  addition  to  these,  it  may  be  injured 
in  fractures  of  the  fibula,  in  pressure  caused  by  tight  bandages  or 
garters  applied  below  the  knee,  or  by  prolonged  compression  in 
extreme  flexion  of  the  leg.  It  may  be  involved  by  the  extension 
of  inflammatory  conditions  around  the  knee-joint,  and  is  fre- 
quently involved  in  toxic  conditions. 

The  symptoms  of  involvement  of  this  nerve  are  paralysis  and 
atrophy  of  the  muscles  situated  on  the  anterior  external  aspect 
of  the  leg  and  the  extensors  of  the  toes,  causing  dropping  and 
adduction  of  the  foot  and  toes,  known  as  foot-drop.  This  gives 
rise  to  a  peculiarity  in  walking  known  as  steppage-gait;  dis- 
turbances of  the  electric  reactions  and  of  sensation  on  the  outer 
side  of  the  leg  and  dorsum  of  the  foot  also  occurring. 

The  prognosis  and  treatment  are  the  same  as  in  affections  of  the 
other  peripheral  nerves. 

Neuritis  of  the  Internal  Popliteal  Nerve. — This  is  not  so 
frequent  as  are  affections  of  the  external  popliteal  nerve.  The 
nerve  may  be  compressed  or  injured,  or  it  may  be  involved  in 
toxic  conditions. 


TRAUMATIC   AND    INFLAMMATORY   DISEASES  205 

Affections  of  this  nerve  give  rise  to  weakness  or  paralysis 
of  the  plantar  flexors  of  the  foot  and  toes,  and  the  individual 
cannot  raise  himself  on  his  tiptoes.  If  the  paralysis  is  extensive, 
deformity  may  occur,  causing  a  claw  position  of  the  toes,  etc. 
Sensation  may  be  diminished  or  absent  on  the  postero-external 
surface  of  the  leg  and  on  the  outer  margin  of  the  foot,  sole  of  the 
foot,  and  plantar  surface  of  the  toes. 

Prognosis  and  treatment  are  the  same  as  those  in  similar 
affections  of  the  peripheral  nerves. 

Neuritis  of  the  Plantar  Nerves. — This  may  be  caused  by 
injury,  such  as  w^alking  upon  very  rough  ground  or  the  wearing 
of  ill-fitting  shoes.  It  may  also  result  from  exposure  to  wet 
and  cold,  etc. 

The  symptoms  consist  of  pain,  tenderness  to  pressure  of  the 
nerves  between  the  long  bones  of  the  foot,  sensory  disturbances 
on  the  sole  of  the  foot,  and  paralysis  or  weakness  of  the  muscles 
that  move  the  toes. 

The  prognosis  is  good  when  the  cause  can  be  removed.  The 
treatment  consists  of  rest,  relief  of  pain,  and  other  measures 
recommended  for  the  treatment  of  neuritis. 

Morton's  Toe. — This  is  a  painful  condition  and  consists  of 
attacks  in  which  the  individual  is  seized  with  a  sudden  sharp 
pain  between  the  toes.  This  is  so  severe  as  to  prevent  his  taking 
another  step,  and  it  lasts  until  the  shoe  is  removed,  and  by 
manipulation  the  metatarsal  bones  are  separated.  These 
attacks  are  likely  to  occur  with  great  frequency.  The  condition 
is  due  to  compression  of  a  digital  branch  of  the  plantar  nerve 
in  its  passage  between  the  ends  of  the  metatarsal  bones,  and  is 
purely  mechanical  in  origin.  It  occurs  in  consequence  of  wearing 
shoes  that  are  too  narrow. 

The  prognosis  is  good.  The  treatment  is  directed  toward 
preventing  pressure  on  the  nerve.  Shoes  should  be  properly 
fitted  and  flat-foot  corrected  if  it  exists.  A  pad  should  be  placed 
between  the  metatarsal  bones,  and  if  this  does  not  give  relief, 
operative  measures  must  be  adopted. 


2o6  MANUAL   OF   NERVOUS   DISEASES 

OCCUPATION   PARESES 

There  are  certain  occupations  in  which,  as  the  result  of  pres- 
sure upon  the  nerves  or  of  overuse  of  a  part  of  the  body,  there 
occurs  weakness  or  paralysis,  with  atrophy  and  sometimes  dis- 
turbance of  sensation. 

These  forms  of  paraylsis  occur  more  frequently  in  the  upper 
extremities,  but  have  also  been  known  to  affect  the  lower 
extremities  and  the  trunk.  Chronic  poisoning  and  general 
debilitating  states  predispose  to  the  condition 

In  occupations  such  as  those  of  ironers,  file-cutters,  locksmiths, 
carpenters,  etc.,  as  result  of  pressure  and  overuse,  an  atrophic 
paralysis  or  weakness  occurs  in  the  small  muscles  of  the  hand. 
Individuals  who  use  the  forearm  excessively  or  lean  upon  hard 
surfaces  with  their  elbows,  as,  for  example,  telephone  operators, 
glass- workers,  oarsmen,  etc.,  are  likely  to  develop  ulnar  paralysis. 

The  course  of  the  disease  is  usually  chronic;  the  onset  is  slow, 
with  a  chronic  or  subacute  development. 

The  diagnosis  is  made  by  the  distribution  of  the  paralysis  or 
weakness,  which  is  flaccid  in  character,  and  which  may  be 
accompanied  by  sensory  symptoms,  and  the  history  of  the 
occupation,  which  will  point  to  overuse  of  and  pressure  upon  the 
nerves  supplying  the  affected  muscles. 

The  prognosis  is  favorable  if  the  cause  can  be  removed. 

The  treatment  consists  in  removing  the  cause;  that  is,  either 
entirely  giving  up  the  occupation  or  modifying  it  in  such  a  way 
as  to  remove  the  possibility  of  pressure  upon  the  nerves.  The 
general  health  should  be  looked  after  and  the  affected  muscles 
massaged.  The  electric  currents  should  be  used — the  faradic, 
if  it  brings  about  muscle  response;  should  this  fail,  the  inter- 
rupted galvanic  should  be  applied. 

MULTIPLE   NEURITIS    (PERIPHERAL   NEURITIS) 

This  condition  is  characterized  by  general  inflammation  or 
degeneration  of  the  nerves.  It  is  usually  more  or  less  symmetric 
in  distribution,  appearing  upon  both  sides  of  the  body,  and 
affects  most  frequently  the  terminal  branches  of  the  nerves. 


MULTIPLE   NEURITIS    (PERIPHERAL   NEURITIS)         207 

The  varieties  of  multiple  neuritis  may  be  grouped  under  four 
heads:  First,  those  cases  caused  by  exogenous  toxins,  such  as 
alcohol,  arsenic,  lead,  mercury,  coal-tar  products,  carbon  mo- 
noxid,  etc.  Second,  those  cases  occurring  in  the  course  of  infec- 
tious diseases,  such  as  diphtheria,  la  grippe,  t^-phoid,  scarlet 
fever,  whooping-cough,  erysipelas,  septicemia,  beriberi,  leprosy, 
etc.  Third,  those  cases  occurring  in  general  diseased  states  of  the 
body,  such  as  rheumatism,  gout,  anemia,  tuberculosis,  S}^hilis, 
senility,  malignant  growths,  arteriosclerosis,  etc.  Fourth,  those 
cases  foUowmg  exposure  to  cold,  and  which  develop  without 
known  cause. 

Multiple  neuritis  affects  men  more  frequently  than  w^omen.  It 
may  occur  at  any  age,  certain  causes  acting  more  frequently  in 
childhood,  whereas  other  causes  are  more  active  in  young  adult 
life.  Probably  the  greatest  number  of  cases  are  seen  between 
the  ages  of  thirty  and  forty  years  in  males.  A  careful  considera- 
tion of  the  histories  of  many  of  these  cases  seems  to  show  that 
there  is  usually  a  complication  of  different  causes  which  leads  to 
multiple  neuritis,  such  as  alcohol  and  exposure,  or  alcohol  and 
an  attack  of  la  grippe,  etc. 

The  symptoms  of  multiple  neuritis,  no  matter  what  the  cause 
may  be,  are  more  or  less  similar  in  the  different  types.  These 
t>T3es  are  due  to  the  fact  that  the  mode  of  onset  differs  in  the 
presence  of  various  causative  agents,  and  these  different  causative 
agents  seem  to  exercise  a  selective  activity  for  certain  nerves. 
We  shall  first  describe  the  general  symptoms  of  this  condition, 
and  then  indicate  only  the  variations  in  different  types.  There 
may  be  a  predominance  of  sensory,  motor,  or  ataxic  symptoms. 
Rarely  the  symptoms  may  be  limited  to  disturbances  of  sen- 
sation or  motion;  usually,  however,  there  is  a  combination  of 
sensory,  motor,  vasomotor,  and  trophic  symptoms. 

The  sensory  symptoms  are  generally  the  first  to  appear,  and 
begin,^as  a  rule,  with  paresthesia,  such  as  numbness  and  tingling. 
This  maybe  associated  with  pain  of  a  burning,  boring,  or  tearing 
character,  to  which  is  often  added  tenderness  of  the  nerves  and 
muscles  which  may  be  so  extreme  as  to  prevent  the  handling  of 
the  affected  parts.  These  sensory  disturbances  are  very  dis- 
tressing to  the  patient,  and  are  apt  to  become  more  severe  as  the 


208 


MANUAL  OF  NERVOUS  DISEASES 


disease  progresses.  Upon  examination  there  may  be  discovered 
at  first  a  hyperesthesia,  which  may  later  go  on  to  anesthesia. 
The  distribution  of  these  sensory  disturbances  is  usually  limited 
to  the  distal  portions  of  the  extremities — such  as  are  covered  by 
gloves  and  stockings.  Moreover,  the  distribution  of  the  sensory 
disturbances  is  always  confined  to  the  areas  supplied  by  the 
peripheral  nerves.  In  incompletely  developed  cases  there  may 
be  loss  of  one  type  of  sensation  with  retention  of  others,  such  as 
loss  of  muscle  sense  with  retention  of  pain  and  temperature 


Fig.  I02. — Foot-drop,  multiple  neuritis  due  to  alcohol. 


sense,  or  loss  of  tactile  with  retention  of  pain  sense.  The 
transmission  of  sensation  is  sometimes  delayed,  but  the  sen- 
sibility to  the  stimulation  is  retained.  When  muscle  sense  is 
seriously  affected,  incoordination  and  ataxia  are  prominent 
symptoms.  Sensory  symptoms  are  practically  always  limited 
to  the  extremities,  and  rarely  involve  the  trunk.  The  special 
senses  are  seldom  affected. 

Motor  Symptoms. — These  generally  manifest  themselves  at 
first  by  a  weakness  which  gradually  extends  and  becomes  more 


MULTIPLE   NEURITIS    (PERIPHERAL   NEURITIS)         209 

marked  until  complete  paralysis  develops.  It  may  come  on 
within  a  few  days,  or  may  gradually  extend  over  a  period  of 
several  months.  It  may  cease  to  advance  at  any  time  in  its 
development.  This  weakness  generally  begins  in  the  distal 
portion  of  an  arm  or  leg,  and  usually  involves  both  sides  at  the 
same  time,  being,  as  a  rule,  more  marked  on  one  side  than  on  the 
other.  The  muscles  supplied  by  the  external  popliteal  nerve  and 
those  supplied  by  the  radial  are  always  more  severely  affected 
than  are  those  supplied  by  the  internal  popliteal  and  the  median 
and  ulnar  nerves.  Consequently  early  in  the  disease  we  have 
greater  weakness  of  the  flexors  of  the  ankles  and  extensors  of 
the  wrist  than  of  the  extensors  of  the  ankle  and  flexors  of  the 
wrist,  this  giving  rise  to  foot-drop  (Fig.  102)  and  wrist-drop. 

As  the  disease  advances  there  is  an  increase  of  paralysis, 
which  extends  to  the  posterior  leg  group  of  muscles,  and  may 
involve  the  thigh  muscles,  the  flexor  muscles  of  the  wrist,  and  the 
muscles  which  flex  and  extend  the  forearm.  In  unusual  cases 
the  muscles  of  the  trunk,  respiration,  and  the  cranial  nerves  may 
also'  become  affected.  The  affected  muscles  show  more  or  less 
atrophy,  and  always  lose  their  normal  tone  and  become  relaxed 
and  flabby. 

The  tendon-reflexes  may  be  somew^hat  increased  in  the  very 
earliest  stage  of  the  disease,  but  after  destructive  changes  have 
taken  place  m  the  nerves  there  is  always  a  loss  of  the  tendon- 
reflexes. 

Electric  examination  usually  reveals  the  fact  that  there  is  a 
disturbance  of  the  normal  reactivity,  partial  reaction  of  degen- 
eration being  present  at  times,  and  complete  reaction  of  degen- 
eration at  others. 

Vasomotor  and  Trophic  Symptoms. — ^These  are  not  so  constant 
as  are  disturbances  of  sensation  and  motion.  In  some  cases  the 
affected  parts  are  covered  by  a  profuse  perspiration;  in  other 
cases  the  skin  may  be  glossy  and  appear  to  be  very  thin.  The 
nails  may  become  thick  and  ridged,  and  there  may  be  an  edema 
of  the  affected  part.  The  involved  area  may  present  a  bluish, 
swollen  appearance  or  be  pale  and  shrunken. 

There  may  be  general  constitutional  symptoms;  these  are 
particularly  apt  to  occur  at  the  onset  of  the  disease,  when  the 
14 


2IO  MANUAL   OF   NERVOUS   DISEASES 

patient  may  have  a  rise  of  temperature  for  several  days  or  weeks, 
a  general  feeling  of  malaise,  gastric  disturbance,  vomiting, 
constipation,  headache,  etc.  Increased  rapidity  of  the  pulse  is 
very  common,  and  may  persist  during  the  entire  course  of  the 
disease. 

Course  and  Prognosis. — These  depend  upon  the  cause  and  the 
possibility  of  its  removal  and  upon  the  severity  of  the  case. 
Some  cases  recover  in  a  few  months,  some  last  as  long  as  two 
years,  and  some  terminate  fatally. 

Differential  Diagnosis. — This  disease  must  be  differentiated 
from  anterior  poliomyelitis,  locomotor  ataxia,  and  diffuse  my- 
elitis.    (See  p.  211.) 

Treatment. — In  treating  these  cases  we  must  first  make  every 
effort  to  remove  and  treat  the  causative  agent.  This,  of  course, 
can  be  readily  done  when  the  disease  is  caused  by  a  known 
exogenous  toxin.  In  all  cases  it  is  advisable  to  put  the  patient 
to  bed,  and  to  give  salines  to  produce  free  purgation.  Water 
and  hot  drinks  should  be  taken  to  assist  in  elimination.  In  the 
early  stages  of  the  disease  the  salicylates,  aspirin,  pyramidon, 
etc.,  seem  to  have  a  good  effect.  Gastro-intestinal  disorders, 
cardiac  disturbances,  fever,  etc.,  all  require  proper  attention. 
Pain  and  tenderness  are  frequently  very  distressing  symptoms, 
and  every  effort  should  be  made  to  relieve  them.  The  pain  can 
sometimes  be  relieved  by  the  coal-tar  products;  at  other  times 
codein  and  morphin  must  be  used.  Pain  may  also  be  relieved 
by  hot  and  cold  applications  and  by  light  massage.  The  tender- 
ness may  be  so  excessive  as  to  prohibit  the  slightest  touch,  and 
under  these  conditions  special  contrivances  must  be  arranged 
to  prevent  the  pressure  of  the  bed-clothes.  Deformity  is  pre- 
vented as  far  as  possible  by  the  arrangement  of  pillows,  etc.,  to 
obviate  improper  positions  of  the  affected  parts.  As  soon  as  the 
acute  stage  has  passed,  strychnin  and  the  hypophosphites  should 
be  administered.  In  those  cases  in  which  we  believe  syphilis 
plays  a  part,  mercurial  inunctions  and  potassium  iodid  should 
be  used  in  conjunction  with  the  strychnin.  In  those  cases  in 
which  malaria  seems  to  play  a  role  quinin  should  be  used  in  com- 
bination with  the  strychnin.  If  the  patient  seems  to  be  anemic, 
iron  preparations  should  be  given.     As  soon  as  the  condition 


MULTIPLE    NEURITIS    (PERIPHERAL    NEURITIS)         211 


^  So' 
2-3 

<  G 


Si's    3 


o 

5j'>-t 

rj-  ps 
C   O 

So 


_■.        C/1    — . 


tfl  tJ^ 


-.y  -■  c  S^ 

c/i   2   CDS 


"  ^  9  c 


X3  P   or;''U  CIT  n 


02 


p  o 


"O  r^^S. 


'"'35      ^-^^ 
B-o  3  33' 

"^    i  in 


C         & 


D-o  a.     "  3- 


rt 


a 


?;  ">  ^ 
3D-0- 


°    3 


la.! 

o 

O    P    3' 


75 

p 

3 

a. 
(-*■ 

3- 
m 
3 


P     ■=!    S     ?  P 

3  2 


m  n; 


3  y 


►DQ 


3  m 


fl    r^.^ 


5-^, 


n 


n 


>0  ri  o) 

t5    P    (T) 

c;  3  3 


Hfl       ►Tl 


0:2, 
=^0 


O   3   3 

3  S--3 


prfs  p 


r^-s  ^ 


3  e        " 
CO  n       3 


sr3  Q 

fD    O    (TJ 
333 


O  P   3 
tfl  f5  B.S  3  W 


3'<' 


en  --3 


—  -  re  " 
'   2  r-c  ^ 


P  3 

■  S|  <  en 

i  3-c  y  £. 


3    3  5;    O    r* 

1>  «        cfl  -.  C 
©"P   3 


W       ^ 


n       ^ 


en   i-f-  p   r^ 


3-n:  "0   3   3 


O     rn 


i^-i  2 


^  ^  -^ 

0_Q-3 


n       ^ 


<3^ 
2-i^'2 


3  3  3  I 


en  C 


0) 


3-3   g 
n>  «  S 

r^-2    P 


■ffi  o  o  7  !=: 


!i  2^<^  P 

3  — ^  3^ 
3  g-  3-05  3 

"-^^§33. 


.3-g   3   3 
p.'        p    l^* 


v^en 

D-P 


Co 


G  o 


"     HI 

3.p 


rrj 


o    iz; 


re  ^- 


P  C  rt  O 

S  5"S.-3 
0.3  c 


pa?  sr 3'tn  o  »  <^ 
-  ^  "  "^  <■§  p. ^2 


n  o  ^r  P  a?  sr  3' 


en  en 


&"0 


3  ji,p 

T    P    ?r 

?^3  2  • 

<-'*'&: 
3  ?5S. 

O-O   3 

3"2^ 

"33 


o-o 


3   5-3-- 

g  re  og: 

O  3  en  re 

►-(  re  re 

re  "2  3  o 

<  en  >g 


•3  C 


_  c  n  7^3:2  -• 
^S<<  ^w  "-^  3 

3"<i  c  3- 
O        en  re 


O  O-p 
re  ^'u! 


W 


?  re 

re  is 


< 


3  a-     i-»- 


2  S.^  ^  ^=:S' 

3  3  r^-  c  ^.  "<  c 

S-o  "H.3-^  g^ 

HI   S  2         O   en  o 

_  ElP  re  s;-<^  re 

-?^^3f;3^ 
o  ,— S  5       3  re 

w   O  5  g  r*  m   2. 

re  ^  iJ  ^  -T- r>  i5 

<  o  O  2^U.T3 

O  re  re  c  2  re  3" 


o-g. 

c/i  3 

Ro 


3'— 
n  ^ 
I  re 
en  1-1 

a-p 


re  tr. 
•o 

2  ^ 

3     HI 

1-»,P 

2\en 
3^re 


3   C 


o  S"^  " 

<  ^  375 

2«  2  2 
"<  3  3-2- 

3  en  1^ 

el'  ■%> 

t3i-  "^ 
-Tre  S- 

3  S".Q- 
"033- 
3  '^  75 

<  -.0 

3'  (^  < 
K    ""    ^ 

3-p 
r»-  re  _, 

ref§ 
3  ^:g 

D-p.  re 

-.3  pr 
3  Q.K 


212  MANUAL   OF   NERVOUS   DISEASES 

will  permit,  massage  and  passive  movements  should  be  actively 
employed  daily,  and  warm  baths,  packs,  and  douches  should  be 
used  to  assist  in  stimulating  the  circulation  and  thereby  increas- 
ing the  nutrition  and  assisting  in  the  reparative  process.  Elec- 
tricity is  one  of  the  most  useful  means  at  our  disposal  for  assisting 
the  progress  of  nerve  regeneration  and  maintaining  muscle 
nutrition. 

The  two  electrodes  should  be  covered  with  clean  gauze,  and  be 
about  one  and  one-half  to  two  inches  in  diameter.  The  current 
which  should  be  used  is  that  which  will  bring  about  contraction 
of  the  muscles  that  are  being  treated.  In  cases  of  partial  reaction 
of  degeneration  I  find  it  advisable  to  use  both  the  faradic  and  the 
interrupted  galvanic  currents.  In  very  mild  cases  the  faradic 
current  suffices;  in  more  serious  cases  at  first  I  use  only  the 
interrupted  galvanic  current  in  the  more  severely  affected  areas, 
and  both  currents  in  those  areas  not  so  markedly  affected.  The 
pole  that  brings  about  the  best  contraction  is  the  one  which  is 
to  be  applied  to  the  affected  area.  In  using  the  interrupted 
galvanic  current  there  should  be  from  60  to  80  interruptions  a 
minute;  this  is  best  attained  by  using  an  automatic  rheotome. 

Electricity  is  beneficial  in  that  it  stimulates  the  regeneration 
of  the  nerve-fibers,  and,  by  producing  muscle  contraction, 
promotes  circulation  in  the  muscle,  stimulates  its  nutrition,  and 
by  exercising  the  function  of  the  muscle,  preserves  its  normal 
irritability.  In  applying  the  faradic  current  one  pole  should  be 
placed  over  the  main  trunks  of  the  nerve  and  the  other  moved 
backward  and  forward  on  the  muscles  and  skin  of  the  affected 
part.  In  applying  the  galvanic  current  the  same  method 
should  be  pursued  as  in  using  the  faradic  current.  When 
however,  we  seek  to  exercise  the  muscle  by  the  employment  of 
the  interrupted  galvanic  current,  the  two  poles  should  be  placed 
over  or  close  to  the  opposite  ends  of  the  muscle  or  muscles  that 
are  being  treated.  The  strength  of  the  current  should  only  be 
such  as  will  bring  about  contraction. 

Contractures  should  be  avoided,  but  if  they  have  occurred, 
may  be  overcome  by  massage;  if  this  does  not  suffice,  they 
should  be  rectified  surgically.  Where  there  is  anesthesia,  the 
patient  should  be  guarded  against  injury,  and  where  trophic 


SPECIAL   FORMS    OF    MULTIPLE    NEURITIS  213 

disturbances  exist,  they  should  receive  proper  attention.  The 
patient  should  be  encouraged  to  make  attempts  at  voluntary 
movements.  His  general  nutrition  should  be  correctly  super- 
vised. In  these  cases  the  results  are  most  satisfactory  if  we  can 
eliminate  the  cause.  Active  treatment  certainly  shortens  the 
duration  of  the  disease  and  prevents  troublesome  sequelae. 

SPECLVL   FORMS    OF   MULTIPLE   NEURITIS 

The  description  just  outlined  will  apply  fairly  well  to  all  forms 
of  multiple  neuritis,  there  being  only  a  few  peculiarities  of 
development  and  distribution  that  are  more  characteristic  in 
one  form  than  in  another. 

Multiple  Neuritis  Due  to  AlcohoL — ^This  is  the  most  conomon 
of  all  forms  of  multiple  neuritis.  Although  the  condition  is 
seen  more  frequently  in  men  than  in  women,  w^hen  one  takes  into 
consideration  the  greater  frequency  with  w^hich  men  are  exposed 
to  intoxication,  it  will  be  seen  that  it  occurs  more  often  in 
women.  It  attacks  by  preference  those  who  use  beverages  in 
which  the  alcoholic  content  is  high,  such  as  brandy,  whisky, 
gin,  rum,  etc.,  but  it  may  also  occur  in  those  w^ho  use  large 
quantities  bi  beer  and  wine.  It  is  more  likely  to  foUow  the 
prolonged  and  constant  use  of  alcoholic  liquors,  rather  than  the 
occasional  overindulgence.  All  ages  may  be  affected,  but  it 
is  most  common  between  the  thirtieth  and  fiftieth  years. 

The  onset  is  usually  gradual,  and  the  patient  may  complain 
for  weeks  or  months  of  gastro-intestinal  symptoms,  neuralgic 
pains,  cramp-like  pains  in  the  legs,  general  weakness,  and 
trembling,  when  suddenly  the  legs  may  give  w^ay  and  the  patient 
fall  and  be  unable  to  rise.  From  this  time  on  the  S}Tnptoms 
are  characteristic :  there  may  be  a  preponderance  of  sensory  or 
motor  s}Tnptoms,  but  usually  there  is  a  combination  of  both. 
There  is  weakness  or  paralysis  of  the  flexors  of  the  ankle,  bringing 
about  foot-drop ;  this  is  followed  by  weakness  of  the  calf  muscles 
and  weakness  or  paralysis  of  the  extensors  of  the  wrist,  causing 
the  grasp  of  the  hands  to  be  impaired  and  perhaps  resulting  in 
wrist-drop.  The  weakness  or  paralysis  is  flaccid  in  t>pe.  There 
is  usually  more  or  less  atrophy  of  the  involved  muscles,  with  loss 
of  the  tendon-reflexes  and  disturbance  of  the  electric  reactions. 


214  MANUAL  OF  NERVOUS  DISEASES 

This  paralysis  and  weakness  may  extend  until  practically  all  the 
muscles  of  the  four  extremities  are  affected,  and  in  rare  cases  the 
cranial  nerves  may  also  be  involved.  The  nerves  are  usually 
sensitive  to  pressure,  and  there  is  marked  muscular  tenderness. 

The  sensory  symptoms  generally  precede  the  motor  symptoms 
for  some  time,  although  this  is  not  invariably  the  case.  At  first 
there  may  be  numbness,  tingling,  and  burning  in  the  legs  and  feet, 
followed  by  pain  of  quite  a  severe  character  and  h^'peresthesia. 
The  pain  and  paresthesia,  which  may  at  first  have  been  intermit- 
tent and  limited  to  the  legs  and  feet,  become  more  constant  and 
more  extensive  in  distribution.  As  the  disease  advances,  in  spite  of 
the  fact  that  pain  may  continue,  examination  will  reveal  delayed 
transmission  of  sensation,  loss  of  epicritic  sensibility,  and  finally 
complete  anesthesia.  These  affect  at  first  small  areas  limited  to 
the  distribution  of  the  terminal  filaments  of  the  anterior  and 
posterior  tibial  nerves,  but  finally  take  the  form  of  stocking-  and 
glove-shaped  areas.  Vasomotor  and  trophic  disturbances  occur 
frequently,  manifesting  themselves  in  a  profuse  perspiration,  a 
bluish  appearance,  edema  of  the  terminal  portions  of  the  ex- 
tremities, etc. 

In  some  cases  m.arked  mental  disturbances  appear.  In  many 
alcoholics  delirium,  confusion,  a  stuporous  condition,  or  transi- 
tory hallucination  occur.  In  conjunction  with  these  there  may 
occur  a  mental  state  known  as  Korsakoff's  syndrome.  This  is 
characterized  by  the  symptoms  of  a  multiple  neuritis  plus 
disturbances  of  memory  for  recent  events,  and  frequently 
disorientation  for  time,  place,  and  person.  In  this  condition 
the  patient,  although  he  may  be  able  to  recall  events  that  have 
taken  place  many  years  previously,  is  unable  to  remember 
incidents  that  have  taken  place  within  the  present,  being  unable 
to  recall  happenings  within  the  space  of  a  few  minutes.  In 
addition  to  this  he  is  frequently  unable  to  recognize  his  surround- 
ings, and  may  believe  himself  to  be  at  home  when  he  is  in  the 
hospital.  He  is  unable  to  recognize  those  about  him,  addressing 
the  doctors  and  nurses  by  the  names  of  his  acquaintances.  He 
is  also  unable  to  realize  the  passage  of  time,  asserting  that  he 
has  been  in  the  hospital  for  a  day  w^hen  in  reality  he  has  been 
there   for   several   months.     Very   frequently   these   lapses   of 


SPECIAL   FORMS    OF    MULTIPLE    NEURITIS  21 5 

memory  are  interwoven  with  fabrication,  the  patient  describing 
in  greatest  detail  events  in  which  he  imagines  himself  to  have 
participated,  but  which  have  never  taken  place.  As  an  ex- 
ample, a  patient  who  has  been  confined  to  bed  for  weeks  in  a 
hospital  will  describe  in  detail  his  experience  at  a  theater  or 
party  on  the  preceding  evening. 

There  is  one  type  of  alcoholic  neuritis  in  which  the  loss  of 
muscle  sense  is  the  most  marked  symptom.  In  these  cases 
ataxia  is  more  prominent  than  the  paralysis,  and  incoordination 
is  the  symptom  which  first  and  most  persistently  attracts 
attention.  This  group  of  cases  may  readily  be  mistaken  for 
locomotor  ataxia,  and  the  condition  is  called  pseudotabes 
alcoholica.  The  gait  in  this  class  of  cases  differs  from  that  of 
the  true  tabetic  in  that  the  latter  throws  the  foot  forward,  lifting 
the  toes  high  in  the  air,  and  bringing  first  the  heel  down  forcibly 
and  then  the  entire  foot.  The  alcoholic,  owing  to  the  weakness 
of  the  muscles  of  extension,  cannot  raise  the  toes;  he  therefore 
lifts  the  foot  high  in  order  to  step  over  the  hanging  toes,  and  then 
throws  the  leg  forward  so  as  to  throw  up  the  toes  to  get  them  out 
of  the  way,  and  then  bringing  the  foot  down  on  the  floor.  This 
is  an  awkward  form  of  the  steppage-gait.  In  addition  to  the 
disturbance  of  the  muscle  sense  there  are  generally  S3anptoms  of 
motor  involvement. 

The  alcoholic  form  of  multiple  neuritis  is  characterized  by  the 
general  constitutional  symptoms  of  chronic  alcoholism,  by  the 
fact  that  it  usually  begins  as  an  affection  of  the  anterior  tibial 
nerves,  in  which  both  sensory  and  motor  symptoms  are  promi- 
nent, by  plantar  hyperesthesia,  and  by  the  development,  in  a 
few  cases,  of  Korsakoff's  syndrome. 

Course  and  Prognosis. — ^Alcoholic  multiple  neuritis  is  usually 
a  subacute  condition,  and  lasts  from  a  few  months  to  two  years. 
In  those  cases  in  which  Korsakoff's  syndrome  is  present  the 
symptoms  of  neuritis  may  clear  up  before  the  mental  manifesta- 
tion disappears.  As  a  rule,  the  mental  disturbance  does  not 
clear  up  entirely,  there  usually  remaining  a  permanent  disturb- 
ance of  the  memory. 

Korsakoff' 's  syndrome  may  terminate  in  complete  recovery,  in 
partial  recovery,  or  in  marked  dementia. 


2l6  MANUAL   OF   NERVOUS   DISEASES 

Treatment. — ^The  great  difficulty  in  treating  this  class  of  cases 
lies  in  the  fact  that  it  is  very  difficult  to  prevent  a  chronic 
alcoholic  from  obtaining  alcohol.  In  spite  of  the  fact  that  the 
patients  know  the  danger  of  using  this  drug,  they  will  get  it  if 
possible.  In  the  treatment  of  these  cases  one  must  always  take 
into  consideration  the  general  condition  of  the  patient,  as  it  may 
be  very  unsafe  to  withhold  alcohol  suddenly  from  an  individual 
who  is  bordering  on  delirium  tremens;  under  these  conditions 
it  is  gradually  reduced. 

Where  there  are  much  restlessness,  tremor,  gastro-intestinal 
disturbances,  etc.,  the  following  preparation  seems  to  be  of 
great  help.  The  doses  must  be  regulated  according  to  the  age 
and  condition  of  the  patient.  If  the  patient  is  unable  to  sleep, 
chloral  hydrate  may  be  added — from  lo  to  20  grains  being  added 
to  the  afternoon  and  evening  doses: 

I^.    Potass,  brom gr.  xv; 

Tinct.  nucis  vomicEe  1  --  _„^. 

Tinct.  gentian  comp.  J 

Oleum  capsici gtt.  ss; 

Ess.  pepsin 5  j- 

The  above  is  one  dose,  and  is  to  be  given  in  water  every  two 
or  three  hours,  the  interval  to  be  lengthened  as  the  patient 
improves. 

The  bowels  must  be  freely  moved  by  salines,  and  the  patient 
encouraged  to  drink  water  freely.  Pain  should  be  relieved  and 
deformity  prevented.  Careful  nursing,  pleasant  and  bright  sur- 
roundings, massage,  electricity,  and  strychnin  in  suitable  doses, 
constitute  the  treatment. 

Arsenical  Neuritis — Multiple  Neuritis  Due  to  Arsenic. — This 
condition  may  occur  from  the  absorption  of  arsenic  or  of  any  of 
its  salts.  Arsenic  may  be  taken  into  the  system  through  the 
gastro-intestinal  tract,  either  accidentally  or  with  suicidal  intent. 
It  may  also  be  taken  into  the  system  during  the  manufacture  of 
certain  substances,  as  in  tin  workers  and  in  employes  of  dyeing 
establishments,  sulphuric  acid  factories,  etc.  It  may  be  taken 
into  the  respiratory  tract  from  the  inhalation  of  particles  of 
arsenic  in  the  air  given  off  from  wall-papers,  carpets,  etc.,  or 
chronic  arsenic  poisoning  may  occur  from  the  use  of  toilet 


SPECIAL   FORMS    OF   MULTIPLE    NEURITIS  21 7 

powder  that  contains  arsenic.  It  may  also  follow  the  prolonged 
use  of  arsenic  for  medicinal  purposes.  The  symptoms  of 
arsenical  neuritis  are  those  already  described.  There  are  certain 
constitutional  symptoms  that  generally  appear  before  the 
symptoms  of  neuritis  manifest  themselves.  If  the  poisoning  is 
acute,  the  symptoms  consist  of  vomiting,  diarrhea,  and  ab- 
dominal pain.  In  chronic  arsenic  poisoning  there  is  a  puffiness 
of  the  eyelids  and  gastro-intestinal  disturbances,  abdominal 
pam,  nausea,  greenish,  mucous  stools,  and  hyperesthesia  occur. 
In  arsenical  neuritis,  as  in  alcoholic  neuritis,  the  first  symptoms 
complamed  of  are  usually  tingling,  numbness,  and  burning  in 
the  hands  and  feet,  h\^eresthesia  of  the  skin  and  muscles,  and 
severe  pain,  described  by  the  patient  as  of  a  tearing,  shooting 
nature.  These  symptoms  are  accompanied  or  followed  by 
weakness  and  finally  paralysis.  The  distribution  of  the  paral- 
ysis is  always  bilateral  and  s}Tnmetric.  In  some  cases  ataxic 
symptoms  may  predominate  at  the  onset  of  the  disease,  but 
sooner  or  later  the  paralytic  symptoms  develop.  This  form  of 
multiple  neuritis  is  characterized  by  extreme  pain  and  tender- 
ness. The  cranial  nerv^es,  trunk,  and  diaphragm  escape.  There 
may  also  be  trophic  disturbances,  such  as  redness,  swelling,  and 
profuse  perspiration,  etc.  The  skin  gradually  becomes  darker 
from  the  deposit  of  pigment,  presenting  a  mottled  appearance, 
and  in  extreme  cases  it  turns  almost  black.  The  mucous 
membranes  are  never  discolored.  Changes  in  the  nails  are  also 
very  common — they  become  thick  and  brittle,  with  transverse, 
roughened  ridges.  Recovery  usually  takes  place  if  the  patient 
does  not  die  from  the  effects  of  the  arsenic  poisoning. 

Treatment  consists  on  the  removal  of  the  cause,  and  is  similar 
to  that  usually  prescribed  for  multiple  neuritis. 

Multiple  Neuritis  Due  to  Poisoning  by  Lead. — This  form  of 
neuritis  is  caused  either  by  the  absorption  of  lead  through  the 
gastro-intestinal  tract,  w^hich  is  particularly  apt  to  occur  in 
individuals  who  work  in  lead  and  w^ho  do  not  thoroughly  wash 
their  hands  before  eating,  or  it  may  enter  the  system  through  the 
respiratory  tract.  Those  who  work  in  badly  ventilated  estab- 
lishments, w^here  lead  or  its  salts  are  used  in  a  dr\"  form,  are  prone 
to  be  affected.     In  most  cases  the  neuritis  is  preceded  by  one  or 


2l8  MANUAL   OF  NERVOUS  DISEASES 

more  attacks  of  lead-colic,  the  patient  suffering  from  abdominal 
pain,  nausea,  vomiting,  and  marked  constipation.  The  patient 
is  usually  anemic,  and  there  may  be  a  characteristic  blue  line 
along  the  gums.  A  few  days,  or  sometimes  several  weeks, 
after  the  attack  has  subsided  the  patient  is  seized  with  weakness 
or  paralysis  of  the  extensors  of  the  wrist  and  fingers,  giving  rise 
to  a  very  characteristic  wrist-drop  (Fig.  103).  In  addition  to  the 
paralysis  the  patient  may  complain  of  severe  muscular  cramps. 


Fig.  103. — ^Wrist-drop  in  a  case  of  multiple  neuritis  due  to  lead  poisoning. 

It  is  only  in  the  markedly  severe  cases  that  the  paralysis  extends 
to  the  muscles  of  the  arms  and  of  the  legs  (Fig.  104).  Usually 
there  is  little  or  no  tenderness  along  the  course  of  the  nerves. 
There  is  also  a  sensory  form,  in  which  the  patient  suffers  intense 
pains  in  the  arms  and  legs,  with  anesthesia  of  the  hands  and  feet. 
Another  variety,  which  is  rare,  is  called  the  cephalic  form;  in 
this  type  there  are  involvement  of  the  cranial  nerves,  headache, 
vertigo,  and  marked  mental  dulness.     The  blood  is  poor  in 


SPECIAL   FORMS    OF    MULTIPLE    NEURITIS 


219 


quality,  and   shows   basophilic   degeneration  of   the   red   cor- 
puscles. 

.    The  prognosis  is  good  in  the  milder  cases,  but  in  the  cephalic 
variety  it  is  very  grave. 

Multiple  Neuritis  Due  to  Illuminating  Gas,  Coal-tar  Products, 
etc. — jMild  forms  of  multiple  neuritis  may  follow  poisoning  by 
illuminating   gas   and   coal-tar   products,    such   as    sulphonal, 


Fig.  104. — Multiple  neuritis  due  to  lead  poisoning,  itvere  case  in  which 
the  paralysis  and  atrophy  involved  the  muscles  of  the  arms,  shoulder,  legs, 
etc. 

trional,  etc.  The  s\Tnptoms  consist  of  tingling  and  numbness 
with  some  weakness  of  the  extremities,  which  may  persist  for 
weeks  or  months,  gradually  subsiding  under  tonic  treatment. 
Postdiphtheric  Neuritis. — ^This  form  of  neuritis  was  formerly 
one  of  the  most  common  varieties  encountered,  but  since  the 
discovery  of  antitoxin  it  has  become  infrequent.  Nevertheless, 
multiple  neuritis  is  encountered  in  children  who  give  a  history 


220  MANUAL   OF   NERVOUS   DISEASES 

of  cold  or  sore  throat  several  weeks  preceding  the  onset  of  the 
illness.  There  is  no  cpestion  in  my  mind  that  in  these  cases  a 
true  diphtheric  condition  has  been  overlooked,  and  it  is  only 
when  the  symptoms  of  neuritis  make  their  appearance  that  the 
true  nature  of  the  disease  is  recognized. 

The  symptoms  may  be  limited  to  dif&culty  in  swallowing  and  in 
speaking,  regurgitation  of  fluids  through  the  nose,  and  there  may 
also  occur  paralysis  of  the  ocular  muscles.  In  nearly  all  cases 
there  is  a  loss  of  the  knee  reflex.  It  has  been  my  experience 
that  in  those  cases  in  which  the  local  disease  has  not  been  recog- 
nized, and  consequently  has  not  been  treated,  if  a  neuritis 
develops,  the  extremities  are  generally  affected,  along  with 
involvement  of  the  ninth  and  tenth  cranial  nerves.  In  the  more 
severe  cases  there  is  loss  of  the  tendon-reflexes,  a  tendency  to 
steppage-gait,  with  weakness  of  the  flexors  of  the  ankle-joints, 
some  disturbance  of  the  muscle  sense,  and  delayed  transmission 
of  sensation.  In  the  very  severe  cases  there  is  great  difficulty 
in  swallowing,  and  weakness  and  atrophy  of  the  tongue,  paralysis 
of  the  vocal  cords,  and  marked  disturbances  in  the  respiratory 
and  cardiac  rhythm.  Diphtheric  paralysis  may  affect  either 
adults  or  children. 

The  prognosis  is  good,  provided  there  is  no  involvement  of  the 
respiratory  muscles  or  pneumogastric  nerve,  and  even  in  these 
cases,  with  very  careful  nursing,  recovery  is  possible. 

The  treatment  is  that  of  multiple  neuritis,  keeping  in  mind 
the  possibility  of  respiratory  and  cardiac  paralysis  and  the 
danger  of  inhalation  of  food.  The  patient  should  be  kept  ab- 
solutely quiet  until  all  the  symptoms  have  disappeared. 

Puerperal  Neuritis. — This  type  of  neuritis  may  occur  during 
pregnancy  or  after  labor.  It  is  due  to  a  toxemia  of  unknown 
origin,  and  does  not  differ  from  the  usual  form  of  multiple 
neuritis.  In  some  cases  the  sensory  symptoms  predominate, 
and  in  others  the  motor  symptoms,  but  usually  there  is  a  com- 
bination of  both.  The  symptomatology  resembles  closely  that 
of  alcoholic  neuritis,  and  in  some  cases  there  is  also  Korsakoff's 
syndrome.     The  prognosis  in  these  cases  is  usually  favorable. 

Beriberi. — ^This  disease  is  characterized  by  certain  con- 
stitutional symptoms  together  with  the  manifestation  of  mul- 


SPECIAL   FORMS    OF    MULTIPLE    NEURITIS  221 

tiple  neuritis.  There  are  two  theories  as  to  its  causation — one, 
that  it  is  due  to  an  infection,  and  the  other,  that  it  is  caused  by 
a  toxic  substance,  such  as  exists  in  improperly  prepared  rice. 
It  occurs  more  frequently  in  males  than  in  females,  and  is  most 
prevalent  between  the  ages  of  sixteen  and  twenty-five.  Ex- 
posure to  damp  and  cold  and  crowded  dwellings  increase  the 
susceptibility  to  the  affection.  It  develops  most  frequently 
during  the  hot  damp  months  of  the  year. 

Symptoms. — ^The  onset  is  generally  gradual,  beginning  with 
moderate  fever,  coryza,  conjunctivitis,  loss  of  appetite,  nausea, 
vomiting,  a  weak,  heavy  feeling  in  the  legs,  and  rapid  fatigue. 
The  fatigue  is  soon  associated  with  numbness  and  pain  in  the 
legs,  and  about  this  time  the  patient  complains  of  palpitation 
of  the  heart  and  tenderness  of  the  muscles.  The  heart  may  be 
irregular  and  rapid,  and  there  may  be  edema  of  the  extremities. 
The  condition  may  not  progress  beyond  this  point,  and  the 
patient  may  recover  in  from  a  few  weeks  to  several  months. 
The  disease  may,  however,  be  more  severe,  and  present  three 
different  types:  The  first  is  the  atrophic  or  dry  type;  in  this  the 
weakness  develops  into  a  true  paralysis,  associated  with  marked 
atrophy  of  the  muscles.  Within  a  short  time  the  paralysis 
spreads  from  the  legs  to  the  arms,  and  may  involve  the  trunk 
and  even  the  face.  The  entire  muscular  system  wastes  aw^ay. 
To  these  symptoms  are  usually  added  sensory  disturbances, 
paresthesia,  general  muscular  tenderness,  and  extreme  pain; 
anesthesia,  when  present,  is  limited  to  the  extremities.  Vaso- 
motor and  trophic  disturbances  frequently  occur.  The  ma- 
jority of  these  cases  recover,  but  convalescence  continues  for 
a  year  or  more. 

The  second  is  the  hydropic  or  wet  type;  in  these  cases  heart 
failure  appears  early,  and  there  is  edema  of  the  entire  body. 
The  swelling  conceals  the  atrophy,  whose  presence  is  indicated  by 
the  fact  that  the  paralysis  is  as  severe  as  in  the  preceding  form. 
In  this  variety  the  prognosis  is  bad,  although  recovery  may  take 
place. 

The  third  is  the  acute  pernicious  type.  In  this  class  of  cases 
the  symptoms  consist  of  rapid  onset  of  paralysis,  edema,  gastro- 
intestinal disturbances,  and  suppression  of  urine.     The  pulse 


22  2  MANUAL   OF   NERVOUS   DISEASES 

becomes  rapid  and  irregular.  This-  type  of  the  disease  may 
run  its  course  to  a  fatal  termination  in  a  very  short  time. 

Treatment. — Change  of  climate,  if  possible,  proper  attention 
to  the  diet,  and  the  relief  of  the  constitutional  symptoms  are 
indicated.  The  treatment  of  the  general  condition  is  most 
important;  as  this  improves,  the  treatment  is  directed  toward  the 
relief  and  cure  of  the  neuritis. 

Leprous  Neuritis. — This  form  of  neuritis  is  due  to  the  presence 
of  the  lepra  bacillus  in  the  interstitial  tissue  of  the  nerve-trunks, 
where,  by  direct  irritation,  it  produces  an  overgrowth  of  the 
connective  tissue,  which  in  turn  causes  pressure  on  the  nerve- 
fibers  and  a  secondary  degeneration.  Small  bulbous  enlarge- 
ments are  found  along  the  course  of  the  affected  nerve. 

The  symptoms  consist  of  the  gradual  development  of  irregular 
areas  of  anesthesia,  the  occurrence  of  paralysis  wdth  atrophy, 
and  the  production  of  trophic  disorders.  The  anesthesia  is 
extremely  irregular  in  its  distribution,  and  may  occur  on  the 
extremities,  trunk,  or  face.  The  paralysis  usually  affects  the 
small  muscles  of  the  hands  and  feet,  and  may  extend  to  the 
larger  muscles  of  the  extremities;  not  uncommonly  the  facial 
muscles  are  involved.  The  trophic  disturbances  which  are 
present,  such  as  the  whitish  areas  on  the  skin,  the  peculiar 
thickening  or  atrophy  of  the  dermis,  the  ulcerations,  etc.,  are 
to  be  regarded  as  a  part  of  the  disease  called  leprosy,  rather 
than  as  the  evidences  of  local  affection  of  the  nerves. 

The  prognosis  is  very  unfavorable,  and  treatment  is  unsatis- 
factory. 

HERPES  ZOSTER 

This  condition  is  characterized  by  an  eruption  of  vesicles, 
which  is  preceded,  accompanied,  or  followed  by  pain,  more  or 
less  severe.  The  eruption  and  the  pain  follow  the  course  of  a 
nerve.  This  condition  affects  by  preference  the  trunk,  in  the 
region  of  the  dorsal  roots,  and  extends  in  the  form  of  a  half- 
girdle.  The  trigeminal  nerve  is  also  often  affected,  particularly 
its  supra-orbital  division.  Herpes  may  occur  along  the  dis- 
tribution of  any  one  or  of  several  nerves.    In  the  great  majority 


HERPES   ZOSTER 


223 


of  cases  the  disease  is  limited  to  one  side  of  the  body,  but  a 
bilateral  distribution  has  been  observed  in  a  few  cases. 

Etiology. — Herpes  may  be  due  to  a  toxemia,  not  infrequently 
it  occurs  in  the  course  of  diseases  of  the  lungs,  pleura,  or  gastro- 
intestinal tract.  It  may  also  be  due  to  gout  or  to  injury  affect- 
ing the  nerves  or  nerve-roots,  or  it  may  be  a  primary  acute 
disease. 

Pathology. — Examination  of  the  ner\'ous  system  generally 
reveals  an  acute  hemorrhagic  inflammation  of  the  ganglia  and 


Fig.  105. — Herpes  zoster;  upper  eyelid  and  supraorbital  region. 
"Atlas  of  Diseases  of  Skin.") 


(Mracek, 


of  the  nerv^es  supplying  the  affected  region.  The  affection  tends 
to  be  limited — frequently  only  one  ganglion  is  involved.  The 
disease  has  also  been  attributed  to  a  peripheral  neuritis. 

Examination  of  the  ganglia  of  the  posterior  roots  and  of  the 
S}Tnpathetic  system  shows  hemorrhagic  and  red-cell  infiltration, 
usually  more  marked  just  between  and  outside  the  capsule  and 
surrounding  areolar  tissue,  and  also  along  the  sheath  of  the 
nerves  supplying  the  affected  area.  The  blood-vessels  show 
marked  congestion.  Gram-positive  diplococci  have  been  found 
quite  constantly  in  areas    at  the   seat  of  lesions  and  in  the 


224  MANUAL   OF  NERVOUS  DISEASES 

ganglia.  From  this  it  would  appear  that  herpes  is  due  to  an 
infection  with  some  form  of  bacteria  that  possess  an  elective 
afhnity  for  the  ganglia  on  the  posterior  roots  of  the  spinal 
nerves  or  on  the  cranial  nerves. 

Symptoms. — The  disease  is  characterized  by  an  eruption  of 
groups  of  vesicles  that  appear  on  a  reddened  base  (Fig.  105). 
The  vesicles  contain  at  first  a  clear  serum,  which  later  becomes 
opaque  and  purulent.  They  then  dry  up,  and  brownish  crusts 
or  scabs  appear  which  fall  off  and  leave  brown  spots,  which  also 
finally  disappear.  The  number  of  vesicles  and  of  groups  varies. 
When  the  eruption  is  close,  the  vesicles  may  become  confluent 
and  form  one  large  blister.  The  development  of  the  eruption 
usually  occupies  a  period  of  several  days,  one  group  following 
another.  It  tends  to  heal,  and  the  entire  process  extends  over 
a  period  of  from  two  or  three  weeks  to  two  months. 

Pain  is  usually  an  accompaniment  of  this  condition.  It  may 
be  very  severe  and  of  a  burning  character,  or  it  may  be  more 
moderate  in  degree.  It  usually  precedes  the  appearance  of  the 
eruption,  and  persists  fur  a  few  days  after  its  appearance;  it  may, 
however,  continue  throughout  the  course  of  the  disease.  Sensory 
disorders  may  occur,  but  are  uncommon.  The  temperature  is 
slightly  elevated,  and  general  constitutional  disturbances  are 
frequently  present. 

The  prognosis  is  usually  favorable.  The  pain  may  last  for  a 
considerable  time  after  the  herpes  has  disappeared.  This  may 
prove  serious  in  old  cachectic  patients. 

Treatment  should  be  directed  toward  the  constitutional 
disease  which  may  exist.  The  vesicles  should  not  be  opened, 
but  should  be  well  covered  with  carbolized  zinc  ointment. 
Friction  should  be  prevented  by  proper  bandaging.  Free 
elimination  should  be  encouraged  by  the  use  of  purgatives  and 
the  drinking  of  plenty  of  water.  Old  and  cachectic  individuals 
require  careful  nursing.  Aspirin  or  the  salicylates,  in  combina- 
tion with  codein,  not  only  relieve  the  pain,  but  apparently 
shorten  the  duration  of  the  disease. 


TUMORS    OF    THE   NERVES  225 

TUMORS    OF    THE    NERVES 

Tumors  of  various  kinds  may  arise  from  the  nerves,  or  be 
localized  in  their  region.  The  nerve-fibers  may  either  pass 
through  or  be  compressed  by  the  tumor.  True  neuromata  are 
very  rare,  most  of  the  new-growths  involving  the  nerves  being 
neurofibromata,  neurosarcomata,  etc.,  which  have  their  origin  in 
the  perineurium  and  epineurium. 

Tumors  of  the  nerves  may  be  solitary  or  multiple.  Multiple 
tumors  may  be  limited  to  the  area  of  one  nerve,  or  may  involve 
the  nerves  of  the  entire  body.  The  size  and  consistence  of 
these  tumors  vary  greatly. 

Tuhercida  dolorosa  is  a  name  applied  to  tumors,  about  the 
size  of  a  pea  or  smaller,  found  singly  or  in  great  numbers  on 
the  sensory  cutaneous  nerves.  They  can  be  easily  felt,  and  are 
usually  very  painful. 

Recklinghausen^ s  disease,  general  neurofibromatosis,  is  a  con- 
dition in  which  numerous  fibromata  occur  on  the  branches  of 
the  nerves.  Pigmented  patches  appear  on  the  skin,  and  these 
are  sometimes  accompanied  by  the  presence  of  nevi  and  angio- 
mata.  In  this  condition  the  tumors  of  the  nerves  vary  in  size, 
and  are  found  not  only  in  the  skin,  but  on  the  visceral  nerves, 
especially  in  the  mesentery  peritoneum,  on  the  sympathetic 
ner\TS,  the  tongue,  the  mucous  membranes,  etc. 

Very  little  is  known  as  to  the  etiology  of  this  condition.  Tuber- 
culosis and  injury  are  believed  to  be  predisposing  causes.  As 
a  rule,  the  tumors  are  of  congenital  origin,  and  often  a  distinct 
heredity  or  familial  tendency  is  seen. 

Symptoms. — In  some  cases  symptoms  may  be  absent,  and  the 
tumors  discovered  by  accident.  In  other  cases  the  tumors 
manifest  themselves  by  intense  pain.  Usually  they  are  very 
tender  to  pressure,  and  their  development  is  accompanied  by 
hj-peresthesia,  and  rarely  anesthesia.  Paralysis  and  atrophy 
also  develop.  The  patient's  general  condition  is  usually  un- 
affected, unless  pain  is  severe,  when  general  wasting  takes  place. 

The  disease  is,  as  a  rule,  a  slowdy  progressive  one,  and  creates 
a  predisposition  for  the  development  of  malignant  tumors  at 
other  sites. 


226  MANUAL   OF   NERVOUS   DISEASES 

Tumors  may  develop  on  the  cut  end  of  an  injured  nerve. 
These  growths  may  be  very  painful  and  tender.  They  may  also 
occur  in  the  neighborhood  of  nerves,  and  by  their  growth  infil- 
trate or  compress  the  nerves. 

Treatment. — If  tumors  are  single  and  give  rise  to  severe  pain, 
they  should  be  extirpated.  Tumors  that  develop  on  the  proximal 
end  of  a  cut  nerve  frequently  recur  after  excision.  The  allevia- 
tion of  pain  is  very  important  in  these  conditions,  and  is  best 
accomplished  by  the  administration  of  the  coal-tar  products, 
codein,  morphin,  etc.  In  some  cases  it  is  necessary  to  inject 
alcohol  into  the  proximal  portion  of  the  nerves ;  in  others  resection 
of  the  more  painful  tumors  is  indicated.  The  patient's  general 
condition  should  also  receive  careful  attention. 

NEURALGIA 

Neuralgia  is  a  disease  characterized  by  the  onset  of  pain, 
more  or  less  severe  in  character,  which  occurs  in  attacks  of 
varying  frequency  and  duration.  It  is  felt  in  the  main  trunk  of 
a  nerve  or  in  its  branches,  or  in  both.  The  disease  may  occur 
at  any  time  of  life,  but  is  very  rare  in  childhood  and  more 
common  after  middle  life.  Puberty,  pregnancy,  the  puerperium, 
and  the  climacteric  period  temporarily  increase  the  predis- 
position to  neuralgia. 

Pathology. — The  pathologic  changes  that  take  place  in  the 
nerves  or  ganglia  are  neither  constant  nor  well  marked.  In 
some  cases  there  is  apparently  a  low-grade  neuritic  or  peri- 
neuritic  change,  or  there  may  be  low-grade  inflammatory  changes 
in  the  ganglia.  In  other  cases  a  sclerosis  of  the  smaller  vessels 
that  go  to  the  nerves  or  the  ganglia  on  the  nerves  occurs.  It  is 
probable  that  the  primary  cause  is  a  disturbance  of  the  nutrition 
of  the  nerve  or  the  ganglia,  giving  rise  to  irritation. 

Etiology. — The  most  important  predisposing  cause  seems  to 
be  a  neuropathic  disposition.  In  many  cases  there  is  a  marked 
hereditary  history,  the  disease  having  occurred  in  the  family  or 
in  the  ancestry.  Among  the  commoner  predisposing  causes 
are  exhausting  illnesses,  severe  hemorrhage,  anemic  conditions, 
old  age,   arteriosclerosis,   constipation,   toxic  agents,   such  as 


NEURALGIA  227 

alcohol,  lead,  mercury,  tobacco,  or  arsenic,  or  it  may  be  the 
result  of  toxins  retained  in  the  system  in  kidney  disorders, 
diseases  of  the  liver,  rheumatic  or  gouty  conditions,  in  diabetes, 
and  in  various  metabolic  disturbances.  Gastro-intestinal  dis- 
orders predispose  to  and  frequently  excite  attacks  of  neuralgia, 
and  compression  or  congestion  of  a  nerA'e,  infectious  diseases, 
exposure  to  cold,  physical  exhaustion,  or  emotional  excitement 
are  all  factors  in  the  etiology.  Reflex  irritation,  such  as  eye- 
strain, adenoids,  etc.;  inflammatory  conditions  in  the  neighbor- 
hood of  nerves  or  injury  to  nerves  or  to  the  surrounding  tissues; 
meteorologic  changes  and  certain  electric  states  of  the  atmos- 
phere may  predispose  to  neuralgia.  The  attacks  seem  to  occur 
more  frequently  in  winter  than  in  summer. 

Symptoms. — The  chief  symptom  is  pain,  which  comes  on  in 
parox}'Sms.  Each  paroxy^sm  may  last  for  several  seconds  or 
recur  at  inten-'als  of  seconds  or  minutes,  and  the  entire  attack 
may  continue  from  a  few  minutes  to  several  hours  or  days.  The 
pain  is  described  as  a  stabbing,  boring,  tearing,  or  burning 
sensation,  which  occurs  along  the  distribution  of  a  ner\T. 
During  the  interval  between  paroxysms  the  patient  is  usually 
free  from  pain,  but  may  experience  a  sensation  of  soreness. 
During  the  attack  the  nerve  is  generally  tender,  and  pressure  on 
such  a  nerve  may  bring  on  an  attack.  Sometimes  the  paroxysms 
of  pain  are  accompanied  by  or  immediately  followed  by  reflex 
automatic  spasms  in  the  muscles,  whose  motor  centers  are  in 
close  relation  to  the  sensory  root  involved. 

The  attack  is  often  accompanied  by  secretory,  motor,  and 
vasomotor  symptoms.  Loss  or  graying  of  the  hair,  falling  out 
of  the  teeth,  and  herpetic  eruptions  are  among  the  frequent 
trophic  disturbances  that  occur  in  neuralgic  conditions.  Paral- 
ysis does  not  occur,  but  the  pain  may  give  rise  to  restriction  of 
active  movement.  The  skin  of  the  affected  parts  is  often 
h}^eresthetic,  whereas  anesthesia  never  develops,  and  decreased 
sensibility  occurs  only  in  the  later  stages. 

Pressure  points,  i.  e.,  circumscribed  spots  that  are  tender  to 
pressure,  are  usually  found  in  the  course  of  the  affected  nerv^e. 
These  points  generally  correspond  to  the  site  at  which  the 
nerve  emerges  from  a  canal  in  the  bone,  or  to  a  site  at  which  it 


228  MANUAL   OF   NERVOUS   DISEASES 

can  be  pressed  against  solid  tissue.  The  nerve  is  seldom  sen- 
sitive to  pressure  throughout  its  entire  course. 

When  the  disease  is  of  long  duration,  the  general  health  of 
the  patient  is,  as  a  rule,  affected.  There  may  be  loss  of  appetite, 
digestive  troubles,  disturbance  of  nutrition,  etc.  In  prolonged 
severe  cases  there  may  be  marked  depression,  and  delirium 
with  attempts  at  suicide  may  develop. 

A  diagnosis  of  neuralgia  should  never  be  made  before  a 
thorough  examination  has  excluded  organic  disease  of  the  nerves 
or  of  the  central  nervous  system,  disease  processes  in  the  neigh- 
borhood of  nerves,  etc.  The  diagnosis  must  also  be  differentiated 
from  painful  attacks  occurring  in  hysteric  individuals,  in  whom 
the  pain  is  of  mental  origin.  This  last  condition  is  called 
psychalgia.  Differentiation  may  be  made  from  the  fact  that  in 
the  latter  mental  change  is  capable  of  influencing  the  pain, 
which  is  increased,  abolished,  allayed,  or  produced  according 
to  the  idea  or  emotion  that  has  occasioned  it.  Moreover,  the 
pain  develops  or  increases  under  observation,  and  disappears 
when  the  attention  is  diverted. 

These  pseudoneuralgias  are  also  not  confined  strictly  to 
nerve-tracts,  nor  are  they  constant  in  their  distribution,  fre- 
quently recurring  in  different  areas.  They  are,  as  a  rule,  more 
diffuse  in  distribution,  more  likely  to  affect  segments  of  the 
body,  such  as  the  entire  head  or  half  of  the  head,  an  entire  arm 
or  leg,  or  one-half  of  the  body,  etc.  Not  infrequently  they  are 
accompanied  by  other  hysteric  symptoms. 

Myalgia  is  differentiated  from  neuralgia  by  the  distribution, 
character  of  pain,  and  the  mode  of  onset. 

Course  and  Prognosis. — Neuralgia  may  have  an  acute  onset, 
may  continue  a  short  time,  and  then  disappear.  It  usually 
comes  on  in  attacks  that  last  for  days,  weeks,  or  months,  with 
intervals  of  considerable  duration  in  which  there  is  more  or  less 
complete  freedom  from  pain.  In  other  cases  there  is  simply  a 
remission  of  pain,  which  may  last  for  a  longer  or  shorter  time. 
In  still  other  cases  the  attacks  follow  each  other  in  rapid  succes- 
sion, the  interval  of  freedom  being  limited  to  a  few  hours. 

The  prognosis  is  favorable  in  recent  cases,  occurring  in  young, 
well-nourished  individuals.      The  neuralgias  that   occur  with 


NEURALGIA  229 

acute  onset  following  the  infectious  diseases  usually  respond  to 
treatment.  Those  occurring  in  individuals  with  a  neuropathic 
heredity,  and  in  older  people  after  long-continued,  exhausting 
disease  or  chronic  poisoning,  present  a  very  unfavorable  prog- 
nosis. 

Treatment. — Before  instituting  treatment  a  most  careful 
and  systematic  examination  of  the  patient  should  be  made  in 
order,  if  possible,  to  discover  the  cause.  This  should,  when 
discovered,  receive  the  proper  treatment.  In  case  of  deficient 
nutrition,  etc.,  improvement  of  the  health  by  diet,  exercise,  etc., 
may  effect  a  cure.  If  the  exciting  cause  is  a  too  rich  diet,  proper 
regulation  of  the  food  may  be  sufficient.  In  neuralgia  the  diet 
should  be  mLxed  and  non-stimulating.  This  is  especially  true  of 
diabetic  and  gouty  individuals.  Susceptibility  to  rheumatic 
influences  is  to  be  combated  by  proper  treatment  of  the  throat 
and  nose  and  by  hydrotherapy.  The  bowels  should  be  regu- 
lated, and  sufficient  physical  exercise  be  taken.  If  malaria  is 
suspected,  quinin  should  be  administered.  When  s}^hilis  is 
believed  to  be  present,  mercury  and  the  iodids  are  to  be  used. 
In  case  of  chronic  poisoning,  the  source  is  to  be  removed  and 
efforts  made  to  eliminate  the  poison.  For  the  pain,  counter- 
irritation  or  blisters  may  not  only  relieve,  but  even  cure,  some 
cases.  Ointments  containing  opium,  belladonna,  or  chloro- 
form may  give  relief.  The  local  application  of  heat,  or  sometimes 
of  cold,  has  a  palliative  effect,  and  in  some  cases  electricity  seems 
to  give  relief.  The  galvanic  current  is  to  be  used,  the  positive 
pole  being  placed  upon  the  affected  nerve  at  its  point  of  origm, 
or  upon  a  pressure  point,  with  the  negative  pole  placed  at  some 
distance.  A  weak  continuous  current  is  passed  through  the 
nerve,  the  strength  of  the  current  being  gradually  increased 
and  the  current  turned  off  and  on  slowly.  The  application 
should  last  from  one  to  thirty  minutes,  and  the  current  should 
never  be  strong  enough  to  give  rise  to  discomfort.  Massage  is 
of  considerable  benefit  in  some  cases,  especially  where  it  is  used 
to  promote  the  general  health.  Change  of  climate  may  be 
necessary.  Drugs  are  used  to  relieve  pain  and  to  cure  the  dis- 
ease. Quinin  in  increasing  doses,  pushed  to  its  physiologic 
limit,  has  proved  beneficial  in  some  cases.     Arsenic  and  iron  are 


230  MANUAL   OF   NERVOUS   DISEASES 

especially  useful  in  anemic  individuals.  Sodium  salicylate, 
salol,  and  aspirin  are  beneficial  in  rheumatic  conditions.  Potas- 
sium iodid  is  frequently  of  value,  and  aconitin  and  nitroglycerin 
are  often  effective  where  blood-pressure  is  high.  Phenacetin, 
antipyrin,  phenalgin,  pyramidon,  etc.,  may  be  given  to  relieve 
pain.  It  is  frequently  found  that  a  drug  which  at  first  gave 
relief,  after  a  time  is  no  longer  effective,  and  under  these  condi- 
tions other  remedies  must  be  tried.  Later  it  may  be  found 
that  the  original  drug  is  again  effective. 

Some  cases  are  very  intractable,  and  in  these  codein  or 
morphin  must  be  used.  In  obstinate  cases  it  is  advisable  to 
inject  the  morphin  in  combination  with  atropin  into  the  neigh- 
borhood of  the  nerve.  Ointments  containing  analgesics  may  be 
rubbed  in  over  a  nerve,  or  ethyl  chlorid,  in  the  form  of  a 
spray,  may  be  applied  over  the  affected  nerve.  The  sub- 
cutaneous injection,  into  a  nerve,  of  i  or  2  drops  of  a  i  per 
cent,  solution  of  osmic  acid  or  carbolic  acid  may  be  tried,  but 
has  no  positive  value.  Injection  into  a  nerve  or  its  immediate 
vicinity  of  an  80  per  cent,  solution  of  alcohol  containing  a  very 
small  amount  of  cocain  and  chloroform,  as  advised  by  Schlosser 
and  Lange,  gives  very  satisfactory  results.  In  those  cases  in 
which  there  is  evidence  of  local  irritation,  surgical  measures 
may  be  adopted.  Those  cases  that  do  not  yield  promptly  to 
medical  treatment  after  a  proper  interval  had  better  be  dealt 
with  surgically — simple  section  of  the  nerve  merely  gives 
temporary  relief,  and  is  mentioned  only  to  be  condemned.  Exci- 
sion of  a  large  portion  of  a  nerve  may  give  permanent  relief. 
Nerve-stretching  may  also  have  a  good  effect,  and  extraction 
of  the  nerve  by  means  of  special  instruments  and  methods  has 
been  very  successful.  Intracranial  or  intraspinal  section  of 
sensory  roots  of  nerves  is  to  be  recommended  in  intractable 
cases. 

NEURALGIA   OF   THE   INDIVIDUAL   NERVES 

Trigeminal  Neuralgia;  Neuralgia  of  the  Fifth  Nerve. — This 
is  the  most  common  form  of  neuralgia.  It  occurs  in  women 
more  frequently  than  in  men.     In  the  majority  of  cases  the  onset 


NEURALGIA   OF    THE    INDIVIDUAL    NERVES  23 1 

is  between  the  twenty-fifth  and  fiftieth  years,  although  no  age 
is  exempt.  As  the  disease  may  be  chronic  in  course,  it  may  exist 
in  individuals  who  are  very  old.  There  is  a  distinct  hereditary 
tendency  to  develop  this  disease.  In  addition  to  the  usual 
causes  of  neuralgia,  disturbances  of  vision,  eye-strain,  ear 
diseases,  diseases  of  the  nose  and  its  accessory  sinuses,  diseases 
of  the  teeth  and  of  the  bones  of  the  face  and  skull,  may  pre- 
dispose to  or  excite  this  form  of  neuralgia.  Exposure  to  cold, 
the  eating  or  drinking  of  very  hot  or  very  cold  substances, 
emotional  disturbances,  and  the  like  are  particularly  prone  to 
excite  an  attack  in  individuals  who  are  predisposed. 

The  principal  pathologic  changes  obsen,^ed  in  this  condition 
are  degeneration  and  low-grade  inflammation  of  the  branches  of 
the  fifth  nerve,  degeneration  of  the  cells  in  the  Gasserian  ganglion, 
and  endarteritis  of  the  vessels  of  the  ner\^e  and  ganglion. 

Symptoms. — The  chief  symptom  is  intense  pain  along  the 
course  of  the  nerve.  It  occurs  in  paroxysms,  and  is  of  a  sharp, 
shooting  character.  It  may  involve  all  the  branches  of  the 
fifth  nerve,  or  may  be  limited  to  one  or  more  branches  of  the 
ner\^e.  The  most  common  form  is  the  neuralgic  pain  that  is 
limited  to  the  supra-orbital  branch,  in  which  the  pain  is  felt 
above  the  eye,  over  the  forehead,  sometimes  in  the  eyeball,  etc. ; 
when  the  infra-orbital  branch  is  affected,  pain  is  felt  upon  the 
cheek,  in  the  upper  teeth,  and  nose;  when  the  third  or  lower 
branch  is  affected,  pain  is  felt  upon  the  cheek  and  lips,  in  the 
lower  teeth,  and  sometimes  in  the  mouth  and  tongue.  In  addi- 
tion to  the  pain  there  are  frequently  present  disturbances  of 
secretion,  of  sensation,  vasomotor,  trophic,  and  motor  symp- 
toms. During  the  attack  there  may  be  increased  salivation, 
watering  of  the  eyes,  and  increased  nasal  secretion,  a  flushing 
of  the  face,  with  injection  of  the  conjunctiva  and  swelling  of  the 
eyelids;  a  hyperesthetic  condition  of  the  skin,  numbness,  or  at 
times  a  decrease  in  sensation,  and  herpetic  eruptions  and  falling 
out  or  turning  gray  of  the  hair.  Motor  disturbances  are  not 
uncommon  in  the  severer  forms  of  facial  neuralgia,  and  when 
they  exist,  consist  of  convulsive  movements  of  the  muscles  of  the 
face.  These  occur  with  the  paroxy^sm  of  pain  (tic  douloureux). 
During  an  attack  the  nerve-trunks  are  very  tender  at  their 


232  MANUAL   OF   NERVOUS   DISEASES 

exit  from  their  bony  canals,  at  the  supra-orbital  notch,  the 
infra-orbital  foramen,  and  the  mental  forapien. 

Course  and  Prognosis. — This  form  of  neuralgia  usually  begins 
as  an  acute  attack.  It  may  respond  promptly  to  treatment, 
and  patients  may  never  have  another  attack,  or  a  second  attack 
may  occur  in  a  few  days,  weeks,  months,  or  years.  This  second 
attack  may  again  respond  to  treatment,  or  the  attacks  may 
occur  w^ith  increased  frequency  until  the  intervals  of  freedom  are 
very  short — the  patient  being  free  from  pain  only  for  a  few  days, 
hours,  or  minutes.  In  other  cases  the  pain  is  continuous,  and 
the  only  relief  the  patient  gets  is  that  afforded  by  medical  or 
surgical  treatment.  The  prognosis  of  a  single  attack  is  good, 
and  it  is  only  when  the  attacks  occur  with  increasing  frequency 
and  are  of  greater  severity  that  the  prognosis  is  unfavorable, 
unless  surgical  intervention  affords  relief. 

The  diagnosis  of  facial  neuralgia  is  readily  made,  the  only 
difficulty  being  to  determine  the  cause,  and  to  differentiate 
between  a  true  neuralgia  and  a  symptomatic  neuralgia. 

Treatment. — A  careful  examination  should  be  made  to  deter- 
mine the  cause  and  to  rectify  or  remove  this  if  possible.  The 
general  health  of  the  patient  must  be  considered,  and  any 
diseased  condition  should  receive  proper  treatment.  Change  of 
climate  may  be  desirable.  Pain  must  be  relieved,  and  in  severe 
cases  opium  or  one  of  its  derivatives  must  be  used.  In  this  class 
of  cases  there  is  great  danger  of  the  patient  acquiring  the  opium 
habit,  and  every  effort  should,  therefore,  be  made  to  avoid  the 
use  of  this  drug.  The  various  coal-tar  derivatives,  analgesic 
local  applications,  electricity,  counterirritation,  heat  and  cold, 
etc.,  should  all  be  tried  before  prescribing  opium.  If  the  patient 
does  not  respond  to  medicinal  treatment,  it  is  unwise  to  wait 
until  the  patient's  physical  condition  is  run  down  before  surgical 
interference  is  advised. 

The  various  surgical  methods  of  treatment  are  as  follows: 
Cutting  the  branches  of  the  fifth  nerve  at  their  points  of  exit 
from  their  bony  canals — a  method  that  is  mentioned  only  to  be 
condemned;  the  injection  of  the  nerves  at  these  points  with  osmic 
acid  or  phenol — a  procedure  likewise  to  be  cautioned  against; 
the  digging  and  tearing  of  nerves  from  their  canals — a  method 


NEURALGIA    OF    THE   INDIVIDUAL   NERVES  233 

that  seems  to  give  relief  for  a  few  months  or  longer;  injecting 
alcohol  into  the  nerves  at  their  point  of  exit  from  the  cranial 
cavity,  according  to  the  method  of  Schlosser  and  Lang — this, 
on  account  of  the  difhculty  and  unpleasant  complications  that 
may  arise,  should  be  undertaken  only  by  one  who  has  had  the 
proper  experience:  it  gives  relief  for  a  year  or  more  and  some- 
times effects  a  permanent  cure.  In  very  severe  cases  the  only 
certain  method  of  obtaining  relief  is  subdural  resection  of  the 
sensory  root  of  the  Gasserian  ganglion.  This  operation  should 
be  performed  only  by  those  who  have  had  the  proper  training. 
After  this  operation  the  affected  side  of  the  face  is  entirely  de- 
prived of  sensation,  and  there  is  great  danger  of  causing  infect- 
ive and  trophic  disturbances  of  the  eyes  unless  proper  care  is 
exercised. 

Cervico-occipital  Neuralgia. — This  condition  is  characterized 
by  pain  in  the  neck  below^  the  occiput  and  the  under  posterior 
aspect  of  the  head.  It  is  caused  by  affection  of  the  cerv^ical 
plexus,  especially  the  great  occipital  nerve.  Spots  painful  to 
pressure  are  situated  over  the  occiput,  posterior  to  the  mastoid 
process,  etc.,  and  the  scalp  is  usually  very  tender.  This  condition 
has  the  same  etiology  as  neuralgia  in  general,  and  the  prognosis, 
course,  and  treatment  are  the  same  as  in  that  condition.  The 
attacks  usually  subside  under  treatment,  but  manifest  a  ten- 
dency to  recur  in  some  individuals. 

Brachial  Neuralgia. — This  condition  is  characterized  by 
paroxysms  of  pain  in  the  distribution  of  one  or  more  of  the  nerves 
of  the  brachial  plexus.  The  pain  may  be  felt  chiefly  in  the 
neck,  but  usually  affects  also  the  arm,  forearm,  and  hand. 
There  are  painful  points  where  the  nerves  are  superficial  and 
can  easily  be  compressed  against  bone.  The  pain  is  intensified 
by  movement.     Herpes  is  a  frequent  complicating  s}Tnptom. 

Diagnosis  is  made  from  the  paroxysmal  character  of  the  pain, 
radiating  along  the  nerve-trunks,  the  nerve-pressure  points,  the 
absence  of  atrophy  and  paralysis,  disturbance  of  the  electric 
reaction,  and  usually  increased  reflexes. 

The  etiology,  prognosis,  and  treatment  are  the  same  as  in  neu- 
ralgia in  general. 

Intercostal  Neuralgia. — This  condition  has  the  same  etiologic 


234  MANUAL   OF   NERVOUS   DISEASES 

basis  as  neuralgia  in  general.  It  occurs  more  frequently  in 
women  than  in  men.  It  evidences  itself  by  sharp  shooting  pain 
around  the  side  of  the  chest,  often  felt  chiefly  in  the  terminal 
branches  of  the  nerve,  in  front  of  the  chest,  or  in  the  axillary  line. 
The  tender  points  are  situated  in  front,  near  the  sternocostal 
line,  in  the  midaxillary  line,  and  near  the  spinous  process. 
Herpes  is  a  frequent  complication. 

Diagnosis. — The  condition  must  be  differentiated  from  organic 
disease  of  the  nervous  system  or  spinal  cord,  from  disease  of  the 
lungs,  pleura,  heart,  etc.  The  diagnosis  is  made  from  the  sharp, 
shooting  character  of  the  pain,  the  existence  of  the  painful  points 
upon  the  chest  at  the  point  of  exit  of  the  nerves,  and  by  the 
limited  distribution  of  the  affection. 

Treatment  is  that  of  neuralgia  in  general. 

Mastodynia — Neuralgia  of  the  Breast. — This  is  a  form  of 
neuralgia  limited  to  the  nerves  of  the  mammary  gland.  The 
pain  comes  on  in  paroxysms,  and  may  be  extremely  severe. 
It  is  usually  associated  with  hyperesthesia  of  the  skin  and  ex- 
cessive sensibility  of  the  nipples.  Pressure-points  are  situated, 
as  a  rule,  under  the  spinous  process  of  the  second  to  the  sixth 
thoracic  vertebrae.  The  disease  occurs  almost  exclusively  in 
middle  age,  and  practically  always  in  women.  Anemia  and  a 
neuropathic  tendency  are  predisposing  causes.  The  attacks 
occur  more  frequently  during  pregnancy  and  lactation  and  after 
injury  or  emotional  excitement.  The  disease  is  also  more 
likely  to  occur  in  women  whose  breasts  are  pendulous. 

The  diagnosis  is  made  by  excluding  tumors,  organic  disease  of 
the  nervous  system,  and  hysteric  states.  The  prognosis  is  that 
of  neuralgia  in  general.  The  treatment  consists  in  applying  light 
compression  bandages,  and  is  that  of  neuralgia  in  general. 

Lumbar  and  Abdominal  Neuralgia. — This  condition  is  similar 
to  intercostal  neuralgia,  except  that  the  pain  attacks  the  lumbar 
and  abdominal  regions  of  the  body.  This  type  of  neuralgia  is 
also  especially  apt  to  be  attended  by  herpes.  The  cause, 
course,  prognosis,  and  treatment  are  those  of  neuralgia  in  general. 

Crural  Neuralgia. — In  this  condition  the  painful  attacks  may 
occur  either  on  the  exterior  surface  of  the  thigh,  as  far  as  the 
knee-joint,  when  the  external  cutaneous  nerve  is  affected,  or  may 


NEURALGIA    OF    THE   INDIVIDUAL    NERVES  235 

involve  the  inner  surface  of  the  thigh  and  leg  as  far  as  the  ankle. 
The  condition  occurs  more  frequently  in  men  than  in  women. 
It  develops  usually  as  the  result  of  hard  muscular  work,  long 
marches,  exposure  to  cold,  or  injury.  It  also  occurs  frequently 
along  with  sciatica.  Painful  points  are  found  in  the  inguinal 
canal,  on  the  front  of  the  thigh,  on  the  inner  side  of  the  knee,  and 
on  the  inner  malleolus.  Herpes  is  frequently  an  accompani- 
ment. 

Prognosis  and  treatment  are  those  of  neuralgia  in  general. 

Sciatic  Neuralgia — Sciatica. — This  is  a  somewhat  common 
form  of  neuralgia,  occurring  more  frequently  in  males  than  in 
females,  and  usually  after  the  twentieth  year.  Among  the 
frequent  causes  of  sciatica  are  exposure  to  cold,  gouty  and 
rheumatic  conditions,  and  chronic  intoxication  of  any  sort. 
Diabetes  is  especially  likely  to  be  complicated  by  sciatic  and 
crural  neuralgia.  Pressure  on  the  nerve  within  the  pelvis,  from 
accumulations  within  the  rectum,  tumors,  a  pregnant  uterus; 
pressure  on  the  nerve  external  to  the  pelvis;  relaxation  of  the 
sacro-iliac  joint,  causing  either  pressure  or  dragging  of  the  nerve; 
relaxation  of  the  plantar  arches;  venous  congestion,  etc.,  must 
all  be  mentioned  as  causes.  Bilateral  sciatica  is  particularly 
apt  to  be  of  diabetic  origin,  or  symptomatic  of  disease  of  the 
spinal  cord,  spinal  column,  sacrum,  pelvis,  etc. 

Symptoms. — The  onset  of  this  condition  is  generally  indicated 
by  a  dragging  sensation  in  the  back  of  the  thigh,  in  the  sacral, 
or  in  the  lumbar  region.  This  sensation  of  discomfort  becomes 
within  a  short  time  more  severe,  being  replaced  by  stabbing, 
burning,  or  boring  pain  which  follows  the  course  of  the  sciatic 
nerve.  This  pain  usually  passes  down  the  back  of  the  thigh  and 
leg,  and  may  involve  the  foot.  It  comes  on,  as  a  rule,  in  par- 
oxysms, but  may  be  continuous,  with  remissions  and  exacerba- 
tions, and  is  especially  apt  to  be  worse  at  night. 

Movements,  as  a  rule,  increases  the  pain,  and  the  patient 
usually  endeavors  to  place  the  leg  and  thigh  in  a  position  of 
semiflexion,  to  keep  it  as  quiet  as  possible,  and  to  protect  the 
sciatic  nerve  from  pressure.  Strain,  coughing,  sneezing,  and 
the  like  are  apt  to  excite  or  increase  the  pain.  The  tender 
points  of  Valleix   are:   one   near   the  posterosuperior  spine  of 


236  MANUAL  OF  NERVOUS  DISEASES 

the  ilium ;  one  over  the  site  of  the  emergence  of  the  nerve  at  the 
great  sciatic  notch;  one  at  the  lower  margin  of  the  gluteus 
maximus  muscle,  between  the  trochanter  and  the  tuberosity  of 
the  ischium;  one  in  the  middle  of  the  thigh  on  the  posterior 
surface;  one  hehind  the  knee;  one  behind  the  head  of  the  fibula; 
and  one  behind  the  external  condyle  of  the  ankle.  The  pain  is 
usually  deep  seated,  and  may  be  increased  by  making  extension 
of  the  leg  and  thigh.  This  point  is  best  brought  out  by  having 
the  patient  lie  upon  his  back,  extending  the  leg  on  the  thigh, 
and  then  flexing  the  entire  leg  and  thigh  at  the  hip-joint.  Pain 
may  be  produced  after  elevating  the  foot  one  or  two  feet  from 
the  bed,  or  it  may  not  be  felt  until  the  thigh  forms  an  angle  of 
90  degrees  with  the  pelvis.  It  is  also  increased  by  making 
abduction  against  resistance,  of  the  unaffected  thigh  (Bonnet's 
sign),  and  by  flexion  against  resistance,  of  the  unaffected  thigh 
(Martin's  sign). 

The  gait  is  usually  affected.  The  patient  limps,  moving  the 
entire  limb  stiffly,  and  there  is  a  slight  flexion  of  the  thigh  on  the 
pelvis,  the  leg  on  the  thigh,  and  some  outward  rotation  of  the 
entire  leg.  In  the  more  severe  cases  the  patient  is  confined  to 
bed,  and  with  the  aid  of  pillows  the  limb  is  kept  in  the  most 
comfortable  position  possible.  In  some  cases  along  with  the 
pain  there  are  spasmodic  movements  and  twitchings  of  the  leg. 
As  a  rule,  there  are  no  marked  sensory  disturbances,  but  there 
may  be  paresthesia.  There  is  no  paralysis  or  atrophy  of  the 
muscles.  Herpes  is  a  common  complication  of  sciatica,  and  may 
be  very  extensive.  The  tendo  Achillis  reflex  is  retained,  and  the 
reflex  on  the  affected  side  is  often  increased. 

Course  and  Prognosis. — ^The  disease  may  be  of  acute  onset, 
and  attended  by  constitutional  symptoms.  Generally,  however, 
the  onset  is  more  gradual,  extending  over  several  weeks  or 
months,  the  pain  becoming  more  severe.  The  condition  may 
continue  for  several  weeks,  months,  or  a  year,  and  then  gradually 
subside,  or  it  may  become  progressive  and  a  true  neuritis  occur. 
In  this  condition  the  entire  nerve-trunk  is  tender  to  pressure, 
there  is  loss  of  the  tendo  Achillis  reflex,  disturbances  of 
sensation,  weakness  or  paralysis  with  atrophy,  may  occur. 
Relapses  are  particularly  apt  to  occur  in  cases  of  sciatica, 


NEURALGIA    OF    THE   INDIVIDUAL    NERVES  237 

especially  after  overexertion.  The  prospects  for  recovery  are 
best  in  recent  rheumatic  and  in  mild  traumatic  cases.  The 
prognosis  is  influenced  by  the  possibility  of  removing  the  cause 
and  of  instituting  proper  treatment. 

Diagnosis. — Sciatica  must  be  differentiated  from  sacro-iliac 
diseases,  flat-foot,  intrapelvic  disorders,  diseases  of  the  hip- 
joint,  tuberculosis  of  the  sacrum  or  spinal  column,  diseases  of  the 
spinal  cord,  muscular  rheumatism,  locomotor  ataxia,  diseases  of 
the  femur,  intermittent  claudication,  sciatic  neuritis,  etc.  The 
diagnosis  is  generally  made  as  the  result  of  careful  physical 
examination. 

Treatment. — The  treatment  consists,  first,  in  making  thorough 
examination  to  discover  the  cause  of  the  condition  and,  if 
possible,  to  remove  it.  The  patient  should  be  placed  at  complete 
rest,  in  a  comfortable  position,  in  which  the  nerve  is  protected. 
Free  purgation  should  be  instituted  at  once.  In  cases  due  to 
cold  or  rheumatism,  warm  packs  and  counterirritation  are  to  be 
employed.  Internally,  salicylates  or  aspirin  are  to  be  given  in 
large  doses  every  two  or  three  hours.  All  movement  is  to  be 
avoided,  and  the  patient  is  best  kept  in  bed.  Baking  of  the 
limb  in  a  hot-air  apparatus  is  beneficial.  In  addition  to  these 
measures,  if  the  pain  is  severe,  it  may  be  relieved  by  codein 
or,  if  necessary,  morphin.  After  the  acute  stage  has  passed, 
or  in  the  chronic  condition,  in  addition  to  the  efforts  to  remove 
the  cause,  potassium  iodid  should  be  administered,  applications 
of  alternate  heat  and  cold,  baking,  immobilization  by  splints, 
properly  administered  massage,  counterirritation,  hot  or  hot 
and  cold  water  under  pressure,  the  continuous  galvanic  current, 
prolonged  hot  sitz-baths,  puncture  of  the  ner\^e  with  needles 
under  proper  antiseptic  precautions,  injection,  into  the  neighbor- 
hood of  the  nerv^e,  of  cold  normal  salt  solution,  etc.,  may  all 
be  tried.  Injecting  alcohol  into  the  sciatic  ner\^e  is  a  method 
to  be  used  only  in  the  most  severe  cases,  as  it  is  likely  to  be 
followed  by  peroneal  paralysis.  Nerve-stretching  may  be  tried, 
especially  if  there  is  reason  to  believe  that  the  nerv^e  is  embedded 
in  cicatricial  tissue. 

Coccygodynia. — This  is  a  condition  characterized  by  severe 
neuralgic  pain  in  the  region  of  the  coccyx.     It  occurs  much 


238  MANUAL   OF   NERVOUS   DISEASES 

more  frequently  in  women  than  in  men.  The  pain  comes  on 
suddenly  or  after  overexertion,  and  is  increased  by  contractions 
of  the  muscles  which  are  inserted  at  the  coccyx.  Local  tender- 
ness is  generally  present,  it  is  especially  apt  to  occur  in  hysteric 
individuals.  If  the  condition  is  one  of  the  symptoms  of  the 
hysteric  state,  it  should  not  receive  local  treatment,  for  this  will 
only  accentuate  the  pain.  As  the  general  condition  improves 
this  symptom  will  disappear.  Those  few  cases  that  are  truly 
neuralgic  in  character  should  receive  the  same  treatment  that 
is  usually  given  in  neuralgia. 

It  is  very  important  to  make  a  careful  examination  and  ex- 
clude painful  local  disease  of  the  pelvic  bones  or  viscera. 


DISEASES   OF  THE  MUSCULAR  SYSTEM 


PROGRESSIVE   MUSCULAR   DYSTROPHY 

Etiology. — Heredity  is  a  prominent  factor  in  these  cases,  as 
there  is  usually  a  history  of  a  similar  condition  existing  either  in 
the  family  or  in  the  ancestry.  Exposure  to  cold,  overexertion, 
trauma,  infectious  diseases,  etc.,  have  all  been  mentioned  as 
among  the  exciting  causes.  The  disease  usually  appears 
before  the  age  of  puberty,  frequently  before  the  sixth  or  seventh 
year. 

The  explanation  offered  by  Starr,  that  this  disease  is  due  to  an 
inherent  defect  in  development  of  the  muscles,  and  that  the 
muscles,  not  being  endowed  with  proper  vitality,  after  a  short 
time  wither  and  die,  seems  to  me  best  to  account  for  this  con- 
dition. 

Pathology. — In  some  cases  there  is  a  simple  progressive 
atrophy  of  the  muscle-fibers,  a  simple  reduction  in  size  of  the 
individual  fibers  taking  place.  In  other  cases  there  is  a  degenera- 
tion of  the  muscle-fibers,  in  which  they  lose  their  striated  ap- 
pearance, leaving  the  muscles  of  a  smooth,  yellowish  tint,  until 
finally  all  the  muscle  substance  vanishes,  and  fatty  tissue  takes 
its  place.  Under  some  circumstances  there  is  a  deposit  of  fatty 
tissue  between  the  muscle-sheaths,  with  degeneration  and 
deposit  of  fat  in  the  muscle-fibers,  and  not  only  is  the  space 
formerly  occupied  by  the  normal  muscle  filled  in  with  fat,  but 
the  fatty  deposit  may  increase  the  actual  size  of  the  muscle, 
and  if  this  goes  on  to  any  extent,  pseudohypertrophy  of  the 
muscle  will  occur.  Along  with  the  atrophy  we  find  occasion- 
ally true  hj^ertrophy  of  individual  muscle-fibers.     With  the 

239 


240  MANUAL   OF   NERVOUS   DISEASES 

changes  in  the  muscle  tissue  there  is  usually  a  proliferation  of 
connective  tissue,  and  if  this,  after  a  time,  contracts  longi- 
tudinally, there  will  be  a  shortening  of  the  atrophied  muscles. 

Symptoms. — Erb,  who  has  gathered  and  analyzed  many 
facts  in  regard  to  this  affection,  divides  the  disease  into  two 
groups:  (i)  Those  in  which  there  is  an  increased  size  of  the 
affected  muscles — either  a  pseudohypertrophy  or  a  true  hyper- 
trophy of  the  muscle-fibers;  (2)  those  in  which  there  is  no  in- 
crease in  size  of  the  muscles.  From  a  clinical  standpoint  the 
following  types  of  the  disease  are  recognized:  (i)  Pseudomuscular 
hypertrophy  of  Duchenne;  (2)  Erb's  juvenile  dystrophy;  (3) 
Duchenne-Landouzy-Dejerine  type  of  dystrophy. 

The  first  type,  or  pseudomuscular  hypertrophy  of  Duchenne, 
makes  its  appearance  in  earliest  childhood.  It  affects  males 
more  frequently  than  females.  It  involves  by  preference  the 
muscles  of  the  calf,  thigh,  pelvis,  and  lumbar  region.  The 
increase  in  the  size  of  the  muscle  extends  over  large  areas,  and 
is  especially  apt  to  appear  in  the  lower  extremities.  The  second 
type,  or  ErVs  juvenile  dystrophy,  is  more  apt  to  occur  in  youth 
and  young  adult  life.  It  generally  first  involves  the  muscles 
of  the  shoulder  girdle  and  upper  arm.  The  third  type,  or 
Duchenne-Landouzy-Dejerine  form  of  dystrophy,  is  characterized 
by  primary  involvement  of  the  facial  muscles.  In  addition  to 
these  three  t3Apes  many  others  have  been  described.  The  dif- 
ference in  classification  arises  from  the  fact  that  cases  occur  in 
which  the  early  symptoms  affect  regions  of  the  body  differing 
from  those  of  the  three  types  described.  The  course  may  vary, 
but  eventually,  as  the  disease  process  progresses,  all  the  types 
present  a  similar  appearance.  Although,  as  a  rule,  there  is  a  dis- 
tinct hereditary  history  in  these  cases,  yet  many  isolated  exam- 
ples of  the  disease  occur.  The  symptoms  generally  develop 
slowly,  and  often  pass  unnoticed  for  a  long  time. 

In  those  cases  in  which  the  muscles  of  the  pelvis,  thigh,  and 
spinal  column  are  first  affected,  the  disorder  first  becomes  ap- 
parent in  walking  and  in  raising  the  trunk  The  gait  is  wad- 
dling, and  difficulty  is  experienced  in  going  up  steps.  The  patient 
falls  readily.  In  raising  himself  from  the  sitting  position  he 
makes  use  of  the  arms,  leans  forward,  places  his  hands  upon 


PROGRESSIVE    MUSCULAR   DYSTROPHY 


241 


his  thighs,  and  in  this  way  brings  the  body  into  the  erect  pos- 
ture (Fig.  106).  When  the  patient  is  in  the  recumbent  position, 
the  manner  of  rising  is  characteristic:  he  turns  first  on  his 
abdomen,  then,  resting  his  hands  upon  the  ground,  he  raises  the 
trunk  until  he  attains  the  kneeling  position;  then  he  lifts  the 
knees  from  the  ground,  and  places  one  hand  upon  the  knee  of 
the  same  side  and  the  other  upon  the  other  knee;  he  then  works 


Fig.  106. — illustrating  the  position  patients  assume  in  arising  from  a  stoop- 
ing to  an  erect  position. 

his  hands  up  his  legs  until  he  attains  the  erect  position.  As  the 
disease  advances  he  cannot  raise  himself  from  the  ground  with- 
out help,  or  without  supporting  himself  on  some  firm  object. 
This  difficulty  is  due  to  weakness  of  the  muscles  which  extend 
the  legs  on  the  thighs,  the  thighs  on  the  pelvis,  etc. 

Lordosis  of  the  lumbar  spinal  column  is  also  usually  a  prom- 
inent s}Tnptom.     It  is  caused  by  weakness  of  the  muscles  that 
keep  the  pelvis  extended  on  the  thighs,  allowing  an  abnormal 
16 


242 


MANUAL   OF   NERVOUS   DISEASES 


inclination  of  the  pelvis  forward  and  downward  to  take  place. 
When  the  shoulder  group  of  muscles  is  involved,  the  shoulder- 
blade  becomes  abnormally  mobile,  there  is  a  drooping  of  the 
shoulders,  and  the  shoulder-blades  stand  away  from  the  throax. 
There  is  marked  interference  with  the  movements  of  the  shoulder 


P 

IHHH 

~1 

i 

^ 

■ 

•  "Sh^^H 

Fig.  107. — Patient  showing  lordosis  in  the  erect  position,  which  disappears 

when  he  is  seated. 


and  arms  (Fig.  107).  In  those  cases  in  which  the  muscles  of  the 
face  are  involved  there  is  frequently  pseudohypertrophy  of  the 
lips,  the  mouth  is  held  slightly  open,  and  the  patient  is  unable 
to  whistle  or  to  pout  the  lips.  There  is  frequently  an  inability 
to  close  the  eyelids  completely  (Fig.  108). 


PROGRESSIVE   MUSCULAR   DYSTROPHY 


243 


The  affection  may  commence  in  any  part  of  the  body,  but  the 
three  types  that  have  been  described  are  characteristic  of  the 
more  common  forms  of  onset. 

The  muscles  most  frequently  affected  are  the  trapezius,  the 
serratus  magnus,  latissimus  dorsi,  infraspinatus,  deltoid,  biceps, 
supinator  longus,  erector  spinae,  pelvic  muscles,  the  glutei,  quad- 
riceps extensor,  adductors  of  the  thighs,  calf  muscles  and  peroneal 


Fig.   108. — Duchenne-Landoiizy-Dejerine  type  of  muscular  dystrophy. 

muscles,  orbicularis  oris,  orbicularis  palpebrarum,  etc.  As  a 
rule,  the  proximal  parts  of  the  extremities  are  more  markedly 
affected  than  are  the  distal  portions.  Some  of  the  muscles 
involved  show  a  decrease  in  size;  others  may  show  an  apparent 
increase  in  size,  or  the  atrophy  or  hypertrophy  may  be  limited 
to  a  part  of  the  affected  muscles. 
The  deep  reflexes  are  usually  decreased  and  eventually  lost. 


244  MANUAL   OF   NERVOUS   DISEASES 

The  mechanical  excitability  of  the  muscles  is  also  decreased  and 
finally  lost.  The  electric  reaction  is  generally  normal,  and  is 
present  in  proportion  to  the  amount  of  muscle  tissue  that  re- 
mains intact.  There  are  no  sensory  disturbances,  and  fibrillary 
tremors  are  absent. 

The  course  of  the  disease  is  usually  protracted.  The  onset  is 
very  gradual,  with  a  slow  increase  of  symptoms.  Contractures 
occasionally  appear  in  certain  muscles. 

The  prognosis  as  to  life  is  good,  the  disease  extending  over 
many  years.  The  patient  usually  dies  of  an  intercurrent  affec- 
tion. In  some  cases  the  disease  advances  to  a  certain  stage  and 
then  becomes  stationary.  The  condition  may  be  associated 
with  hysteria,  mental  weakness,  epilepsy,  and  congenital 
anomalies  of  the  bony  structures  of  the  body. 

Diagnosis. — The  peculiarity  of  the  figure  and  attitude,  the 
coexistence  of  atrophy  and  hypertrophy,  present  so  character- 
istic an  appearance  that  there  is  usually  no  difficulty  in  making 
the  diagnosis.  The  absence  of  sensory  disturbances  and  of 
fibrillary  tremors;  the  fact  that  the  electric  reaction  is  normal 
in  type  but  present  only  in  proportion  to  the  amount  of  muscle 
tissue  present;  the  age  of  onset;  the  location  of  the  muscles 
involved,  etc. — are  all  points  that  assist  in  differentiating  this 
disease  from  other  conditions  that  are  characterized  by  atrophy 
and  weakness,  such  as  neuritis,  the  spinal  form  of  progressive 
muscular  atrophy,  Friedreich's  disease,  etc.  The  greatest  dif- 
ficulty lies  in  recognizing  the  affection  in  its  earliest  incipiency, 
and  here  a  careful  study  of  the  case  is  necessary. 

Treatment.— This  consists  of  rest,  with  gentle  systematic 
exercise;  general  massage,  properly  given;  electric  treatment, 
especially  the  galvanic  current;  nourishing  food,  fresh  air,  and 
pleasant  surroundings;  and,  when  necessary,  supporting  ap- 
paratus to  prevent  deformity  or  to  enable  the  patient  to  walk, 
etc. 

POLYMYOSITIS 

Polymyositis  is  a  condition  characterized  by  pain,  tenderness, 
and  weakness  or  paralysis  of  the  muscles,  the  last  of  which  comes 
on  rapidly. 


POLYMYOSITIS  245 

Etiology. — This  condition  may  be  acute  or  chronic.  It  affects 
any  age,  men  being  more  prone  to  be  affected  than  women.  It 
may  occur  in  tubercular  individuals  or  during  the  puerperium, 
it  may  follow  influenza,  tonsillitis,  gastro-intestinal  intoxications, 
exposure  to  excessive  cold,  infection,  etc. 

The  pathologic  changes  that  take  place  are :  A  parenchymatous 
or  interstitial  myositis,  involving  all  or  any  of  the  muscles  of  the 
body;  serous  infiltration,  with  a  mottled,  grayish-yellow  appear- 
ance of  the  muscle  tissue,  which  mav  be  firm  or  soft  in  con- 
sistency. 

Symptoms. — The  disease  is  usually  of  acute,  but  not  of 
sudden,  onset.  It  manifests  itself,  as  a  rule,  with  general 
constitutional  symptoms.  There  is  a  feeling  of  exhaustion, 
with  heaviness  of  the  limbs;  this  may  be  accompanied  by  head- 
ache, vertigo,  and  gastro-intestinal  symptoms.  From  the  first, 
or  within  a  few  days,  there  is  a  marked  dragging  pain  in  the  mus- 
cles, and  the  patient  gradually  becomes  weaker  until  finally  he  is 
more  or  less  completely  paralyzed.  The  proximal  parts  of  the  ex- 
tremities are  usually  more  severely  affected  than  the  distal  parts. 
The  muscles  are  tender  to  pressure  and  passive  movements 
cause  pain.  The  muscles  are  generally  swollen,  and  the  skin  and 
subcutaneous  tissues  are  frequently  edematous  and  infiltrated, 
this  being  more  marked  over  the  affected  muscles.  The  arms 
are,  as  a  rule,  more  severely  affected  than  the  legs.  The  skin 
may  be  reddened,  and  this  sometimes  suggests  er\^sipelas. 
Hyperidrosis  is  frequently  present.  This  condition  may  be 
limited  to  a  very  few  muscles,  to  the  muscles  of  one  extremity, 
or  may  be  irregular  in  distribution.  The  muscles  of  respiration 
and  deglutition,  the  tongue,  the  diaphragm,  the  heart,  etc.,  are 
rarely  aft'ected.  There  are  no  sensory  disturbances.  The  mind 
remains  clear  except  in  so  far  as  the  acti\dty  of  the  brain  is 
interfered  with  by  the  action  of  fever,  weakness,  and  general 
intoxication.  The  tendon-reflexes  corresponding  to  the  affected 
muscles  are  usually  decreased  or  lost,  and  there  is  commonly 
a  rise  of  temperature  throughout  the  course  of  the  disease.  This 
condition  must  be  differentiated  from  trichinosis,  from  which  it 
is  readily  distinguished  by  the  fact  that  the  latter  may  affect 
a  number  of  individuals  who  have  eaten  meat  from  the  same 


246  MANUAL   OF   NERVOUS   DISEASES 

animal,  and  by  the  marked  prominence  of  the  gastro-intestinal 
symptoms  at  the  onset  of  the  disease.  Moreover,  in  trichinosis 
the  edema  of  the  face  and  eyelids  develops  early,  and  there  is 
marked  increase  of  the  eosinophile  cells  in  the  blood. 

Course. — The  disease  may  last  for  weeks,  months,  or  even  for 
several  years.  It  may  terminate  in  recovery  in  a  few  weeks  or 
end  in  death.  It  may  also  run  an  intermittent  course.  In 
chronic  cases  remissions  are  not  uncommon. 

The  prognosis  as  to  life  is  grave,  except  in  those  cases  that 
have  assumed  a  mild  course  from  the  first. 

Treatment  consists  principally  of  free  elimination,  good  nurs- 
ing, proper  food,  and  hydrotherapy. 

ISCHEMIC   PARALYSIS    (VOLKMANN'S   PARALYSIS) 

This  condition  usually  occurs  after  an  injury,  such  as  a  frac- 
ture, in  which  a  bandage  has  been  applied  too  tightly  or  in  which, 
after  the  application  of  the  bandage  or  of  a  plaster  cast,  swelling 
occurs.  As  a  result  of  pressure  there  is  an  extensive  interference 
with  the  circulation  in  the  affected  part,  and  the  distal  portion 
of  the  affected  limb  presents  a  bluish  appearance  and  may  be 
cold  to  the  touch.  There  is  usually  very  great  pain ;  if  the  pres- 
sure is  not  relieved,  paralysis  follows,  with  disintegration  of 
muscle  tissue,  which  is  followed  by  marked  atrophy  and  second- 
ary contraction. 

The  prognosis  in  this  condition  is  grave,  as  recovery  does  not 
take  place  unless  the  condition  is  discovered  very  early. 

Treatment  consists  in  avoiding  tight  bandages.  When  pain  is 
complained  of,  the  bandages  should  always  be  promptly  removed. 
If  the  condition  is  discovered  early,  warm  applications  and 
gentle  massage  are  indicated.  If  the  damage  has  already  been 
done,  the  best  that  can  be  hoped  for  is  relief  or  rectification  of 
deformity;  this  is  accomplished  by  massage,  hot  applications, 
and  lengthening  of  the  tendons. 


oppenheim's  disease  (myatonia  congenita)     247 

THOMSEN'S    DISEASE    (MYOTONIA  CONGENITA) 

This  condition  is  characterized  by  its  marked  hereditary 
tendency,  great  M^pertrophy  of  muscle-fibers,  and  a  proUferation 
of  the  muscular  nuclei.  The  disease  was  first  described  by  Dr. 
Thomsen,  in  whose  family  over  twenty  cases  occurred  in  four 
generations.  The  condition  generally  becomes  evident  early  in 
life,  but  may  not  develop  until  early  adult  life,  or  it  may  follow 
some  mental  excitment.  Cold  or  emotional  disturbances  in- 
crease the  severity  of  the  affection,  whereas  active  exercise  tends 
to  dimmish  its  severity. 

Symptoms. — The  characteristic  symptom  of  this  affection  is  a 
peculiar  rigidity  of  the  muscles  occurrmg  after  they  have  been  at 
rest  for  some  time.  The  patient  finds  that,  after  resting,  he 
cannot  voluntarily  perform  any  act  until  he  has  made  several 
efforts  to  do  so ;  with  repeated  effort  free  movement  is  finally 
brought  about,  but  after  another  period  of  rest  the  rigidity- 
returns.  In  some  cases  the  muscular  stiffness  becomes  evident 
only  during  very  cold  weather.  Mechanical  excitability  of  the 
muscles  is  increased;  pressure  or  percussion  of  the  affected 
muscles  gives  rise  to  slow,  tonic,  persistent  contrations.  Upon 
application  of  the  electric  current  the  myotonic  reaction  is 
elicited.  There  are  no  disturbances  of  sensation  or  of  the 
organic  reflexes.  The  knee-jerk  is  often  decreased  and  some- 
times lost.  Cases  Yenry  in  severity,  the  very  mild  ones  manifest- 
ing no  marked  s}Tnptoms. 

The  diagnosis  is  readily  made  from  the  hereditary  character  of 
the  disease  and  the  peculiar  reaction  to  the  electric  current. 

The  prognosis  as  to  life  is  favorable,  but  as  to  recovery  or 
improvement  it  is  very  bad.     There  is  no  known  treatment. 

OPPENHEIM^S   DISEASE    (MYATONIA   CONGENITA) 

This  is  a  very  rare  condition,  occurring  in  early  childhood, 
and  characterized  by  atony  of  the  muscles  (Figs.  109,  no).  It 
is  probably  due  to  delayed  development  of  the  musular  system. 
The  muscles  of  the  eyes,  tongue,  throat,  and  respiration  do  not 
seem  to  be  involved.     From  the  very  first  there  is  noticed  an 


248 


MANUAL   OF   NERVOUS   DISEASES 


absence  of  the  normal  movements  of  the  lower,  and  sometimes 
of  the  upper,  extremities.  There  is  a  striking  flaccidity  of  the 
affected  muscles,  and  the  tendon  reflexes  are  weakened  or  lost. 
The  muscles  are  not  visibly  wasted,  but  their  electric  excitabil- 
ity is  diminished  or  lost.  Active  movements  are  feebly  executed, 
and  the  child  may  appear  to  be  paralyzed,  yet  on  close  examina- 
tion it  will  be  seen  that  a  certain  amount  of  movement  is  evident. 


Fig.  109. — Myatonia  congenita,  showing  inability  of  patient  to  sit  erect. 


The  joints  are  usually  movable,  and  the  limbs  may  be  placed  in 
very  abnormal  positions.  There  are  no  disturbances  of  sen- 
sation, and  at  the  proper  age  there  is  control  of  the  rectal  and 
vesical  reflexes. 

The  prognosis  is  not  good,  as  the  majority  of  cases  die  from 
an  intercurrent  affection.  In  those  who  have  survived,  slight 
improvement  has  been  known  to  take  place. 


PERIODIC   PARALYSIS 


249 


HUH 
Fig.  no. — Myatonia  congenita,  showing  abnormal  mobility  of  joints. 


PERIODIC    PARALYSIS 

This  disease  is  characterized  by  a  rapidly  developing  general 
paralysis  of  all  the  muscles  excepting  those  of  respiration  and 
deglutition.  This  paralysis  may  last  for  a  few  hours,  for  sev- 
eral days,  or  even  longer.  The  condition  develops  within 
the  course  of  a  few  hours,  usually  attacking  an  individual  who 
is  apparently  in  good  health.  It  is  not  attended  by  constitu- 
tional symptoms.  There  is  generally  a  history  of  similar  attacks 
in  the  family  or  in  preceding  generations.     This  condition  is 


250  MANUAL   OF   NERVOUS   DISEASES 

believed  to  be  due  to  the  action  of  a  toxic  substance  upon  the 
motor  filaments  of  the  nerves  or  upon  the  muscles. 

Symptoms. — There  is  a  comparatively  rapid  loss  of  muscular 
power,  unattended  by  pain  or  sensory  disturbances.  The 
paralysis  is  flaccid  in  type,  and  there  is  a  loss  of  the  tendon- 
reflexes,  with  completeloss  of  muscle  contraction  to  the  galvanic 
or  the  faradic  current.  The  paralysis  may  be  very  extensive, 
involving  all  the  muscles,  or  it  may  be  limited  to  some  of  the 
muscles  of  the  upper  and  lower  extremities.  The  attack  may 
come  gradually  over  a  period  of  several  hours  and  continue  for 
hours  or  days,  the  patient  gradually  recovering  strength  and 
returning  to  the  normal.  The  seizures  usually  occur  in  parox- 
vsms,  which  may  extend  over  a  period  of  several  weeks.  The 
individual  paroxysm  may  be  mild  or  severe,  a  mild  one  fre- 
quently being  followed  by  a  severe  one.  As  a  rule,  there  is  an 
interval  of  several  months  or  years  between  attacks. 

Treatment. — ^As  the  causative  agent  has  not  been  discovered, 
treatment  is,  to  a  large  extent,  symptomatic.  It  consists  of 
elimination  by  the  use  of  purgatives,  diuretics,  etc.  Alkalis 
seem  to  have  a  beneficial  effect.  A  tropin  is  indicated  if  there 
is  any  respiratory  embarrassment,  and  stryxhnin  in  proper  doses 
should  be  given  throughout  the  attack. 

DISEASES    OF    THE    CRANIAL    NERVES 
DISEASES   OF  THE  FIRST   OR   OLFACTORY  NERVE 

Etiology. — This  ner\^e  may  be  affected  in  acute  or  catarrhal 
conditions  of  the  nasal  mucous  membrane,  disturbances  of  the 
nasal  secretion,  tumors  in  the  nose,  diseases  of  the  ethmoid 
bones  or  ethmoid  cells,  diseases  within  the  anterior  fossa  of  the 
skull  which  bring  about  compression  or  involvement  of  the 
olfactory  bulbs  or  tracts,  such  as  basilar  meningitis,  fracture  of 
the  skull,  tumors  of  the  brain,  etc. 

Symptoms. — If  only  one  of  the  olfactory  nerves  or  tracts  is 
destroyed,  there  is  usually  no  evidence  of  the  condition.  In 
those  cases  in  which  the  conductivity  of  both  nerves  or  tracts 
is  interfered  with  there  is  loss  of  the  sense  of  smell  or  anosmia. 


-XH/ASMA 


CUDDEN^S    COMMISSURE 


THALAM.UJS 

ANT  ^UADRlCEM'NA...- 


WUCLEUS  »f.-- 
m  NERVE 


Int.  CfNicuLATE  BODy 

'■'AND    NERVE    CELLS 

.EKT.   C£MIC(/LAT£   BODY 
MD  MERVE    CELLS 


^ST   9UA0R/G£MIAIA 


OPTIC    RADIATIOM 


''PfTAL  LOBt 


^HT  OCC'P^"^ 


Fig.  no  a. — Showing"  course  of  visual  impulses  from  point  of 
apparent  origin  in  the  visual  fields  to  the  centers  of  visual  perception 
(diagrammatic). 


DISORDERS    OF    THE    SECOND    OR   OPTIC    NERVE        25 1 

Irritation  of  one  or  both  tracts  may  give  rise  to  a  condition  in 
which  the  patient  perceives  an  odor,  either  agreeable  or  disagree- 
able, without  the  true  existence  of  an  odor ;  this  is  a  true  halluci- 
nation of  smell,  and  is  called  parosmia.  Disturbance  of  the 
function  of  the  first  nerve  is  of  interest  principally  from  the 
assistance  it  gives  in  diagnosing  diseases  of  the  structures  with 
which  it  comes  into  apposition.  Primary  disease  of  the  first 
nerve  itself  is  extremely  rare.  The  treatment  of  the  condition 
is  the  discovery  of  the  cause  and  its  removal,  if  possible. 

DISORDERS   OF  THE   SECOND    OR   OPTIC   NERVE 

Before  taking  up  a  study  of  the  diseases  of  the  optic  nerve,  it 
is  well  to  refer  to  the  diagram.  (See  Fig.  iioa.)  This  diagram 
demonstrates  that  symptoms  arising  from  involvement  of  the 
various  portions  of  the  visual  pathway  vary  widely.  When  the 
terminal  filaments  of  one  optic  nerve  are  affected,  or  when  one 
optic  nerve  is  diseased,  there  is  disturbance  of  vision  in  the  eye 
supplied  by  that  nerve.  When  an  optic  tract  or  pathway 
posterior  to  the  tract  is  affected,  there  is  disturbance  of  vision  in 
one-half  of  each  eye,  a  condition  known  as  homonymous  hemi- 
anopsia. In  the  optic  chiasm  the  symptoms  depend  upon  the 
extent  of  involvement  and  the  position  of  the  lesion.  If  the 
lesion  is  very  extensive,  there  may  be  partial  or  total  blindness. 
If  the  lesion  involves  only  the  lateral  aspect  of  the  chiasm,  the 
fibers  that  originate  in  the  temporal  portion  of  one  eye  are  af- 
fected, and  the  condition  gives  rise  to  blindness  in  the  inner  por- 
tion of  the  visual  field  of  one  eye,  i.  e.,  unilateral  nasal  hemianopsia. 
If  the  lesion  involves  only  the  anterior  or  the  posterior  part  of 
the  chiasm,  the  fibers  that  come  from  the  nasal  half  of  both 
retinae  are  involved;  this  gives  rise  to  blindness  in  the  outer 
portion  of  the  visual  fields  of  both  eyes — bilateral  temporal 
hemianopsia.  Central  vision  is  usually  affected  only  in  diseases 
of  the  nerve  itself.  Examination  for  disturbance  of  vision  is 
made  by  testing  the  acuteness  of  vision  and  determining  the 
visual  fields  for  both  eyes  and  for  each  eye.  In  addition  to  the 
stimuli  that  result  in  vision,  other  stimuli  are  transmitted  by  the 
optic  nerv'C  which  reflexly  affect  the  nuclei  of  the  third  nerve, 
and,  through  this  nerve,  result  in  contraction  and  dilatation  of 


252 


MANUAL  OF  NERVOUS  DISEASES 


the  pupils.  Diseases  that  prevent  the  transmission  of  the 
stimuU  through  the  optic  nerve  or  from  the  optic  nerve  to  the 
third  nerve,  and  through  these  to  the  ciliary  muscles,  may 
bring  about  disturbance  of  the  pupillary  action.  For  the  more 
technical  details  of  examination,  etc.,  the  reader  is  referred  to 
the  various  text-books  on  ophthalmology.  For  the  general 
methods  of  examining  for  visual  and  pupillary  disturbances 
reference  should  be  made  to  the  chapter  on  Examination  of 
the  Patients. 

Edema  of  the  Optic  Nerve,  or  Choked  Disk. — In  this  condition 
there  is  an  elevation  of  the  optic  disk,  attended  by  venous 


^B 

^^^^H|l^^^#^  !?^'K^Ir':'^^^ 

^^^^^K^ii'!'' 

mlikmA ,  -i^^^^^B 

^^^^H^?%, 

'%'.;'■:  ",'":f:']i'-J!\    "* 'i^Wm^.wX^X^JM&I^^^^U 

^^V 

;^:<r^.                               ^^^SSbSKs^S^^^ 

■Lg. 

^"^^^^^^aH 

^^^^K 

'^^^^^^^S^l 

B^^p- 

^'^^^S^jy    \  ,.,%"^^^^^M 

^^^^^ 

tm^^v:,      ■^:s  "^^  '■MsJ0^-  -        -    *i^^l 

^^H^H 

^^te&;;M  xisi!^' '■,■'' ■  ■■'i^^^B 

^^^^^^ 

^^i^&Syfa(M«i^%,'I\          ■  ''iiN^^B 

^^^In''''' 

.■:'■""  r   ■'■  '  "i  rW\^S-^"';"'''t''#fSs''?v-\,if;isi«»^l4|^ 

^^^^1^^'^' 

J'  '                      ^Siipi!)?<Ss*'s^^ 

^^^^Hk^ 

fS:':-      „                                       ■jpf^O-'£#;..''^^'^****ji^^^^^H 

ife^##i^i^H 

^^^^^^H 

HI 

^^^^KSi^iiii^&S^^H'itihifi^^i^Siilf^^^^^^^^^^^^^^M 

Fig.  III. — Choked  disk. 


congestion.  This  may  take  place  without  impairment  of  the 
vision.  There  is  usually  no  evidence  of  inflammation,  but 
small  hemorrhages  into  the  retinae  may  occur.  This  condition 
is  generally  secondary  to  increased  intracranial  pressure,  or 
may  arise  in  any  condition  in  which  there  is  obstruction  to  the 
circulation  in  the  eye.  It  is  frequently  present  in  cerebral 
tumors,  abscesses  of  the  brain,  extensive  hemorrhages  into  the 
brain,  meningitis,  edema  of  the  brain,  etc.  If  choked  disk 
continues  for  any  length  of  time,  the  vision  is  usually  impaired. 
In  some  cases  visual  disturbances  occur  early.    The  only  pos- 


DISORDERS    OF    THE   SECOND    OR   OPTIC   NERVE        253 

itive  means  of  making  the  diagnosis  is  from  an  ophthalmoscopic 
examination.  Treatment  consists  in  removing  the  cause,  and 
if  the  latter  connot  be  rapidly  discovered,  decompression  opera- 
tions are  justifiable  (Fig.  in). 

Optic  Neuritis. — This  condition  is  usually  secondary  to  other 
conditions,  and  may  be  caused  by  exogenous  toxins,  such  as 
alcohol,  tobacco,  or  arsenic;  or  endogenous  toxins,  as  in  nephritis, 
diabetes,  or  gout;  or  it  may  occur  during  the  course  of  infectious 
diseases,  in  severe  anemia,  s^^hilis,  after  exposure,  in  meningitis, 
etc.     In  addition  to  the  secondary  forms  of  optic  neuritis,  there 


Fig.  112. — Neuroretinitis. 

also  occur  occasionally  cases  in  which  no  cause  is  discoverable. 
Optic  neuritis  may  be  a  hereditary  condition,  in  which  case  the 
symptoms  usually  occur  in  young  adult  life  and  progress  until 
blindness  ensues  (Fig.  112). 

Optic  neuritis  is  generally  bilateral,  although  one  nerv^e  may 
be  affected  before  the  other,  and  one  may  show  more  extensive 
uivolvement  than  the  other. 

Symptoms. — ^These  consist  of  sensitiveness  to  light;  objects 
appear  indistinct,  and  there  seems  to  be  a  haze  or  cloud  before 
the  eyes,  or,  less  often,  rapid  loss  of  vision,  and  finally,  unless  the 
condition  is  arrested,  blindness  ensues. 


254  MANUAL   OF   NERVOUS   DISEASES 

Diagnosis  is  made  as  the  result  of  ophthalmoscopic  examina- 
tion. The  prognosis  depends  upon  the  possibility  of  removing 
the  cause.  If  the  cause  can  be  removed  before  the  nerve  has 
been  completely  destroyed,  partial  vision  is  regained. 

Treatment  consists  in  removing  the  cause,  if  possible.  Com- 
plete rest  of  the  eyes  should  be  enjoined.  In  some  cases  cerebral 
decompression  is  indicated.  Counterirritation  over  the  temples 
is  also  useful.  Potassium  iodid  in  proper  doses  and,  after  the 
acuteness  of  the  disease  has  passed,  strychnin  should  be  given. 


Fig.  113. — Simple  atrophy  of  the  optic  nerve. 

Optic  Atrophy. — ^This  condition  may  occur  as  a  primary 
affection,  or  it  may  be  secondary  to  some  other  disease.  As  a 
primary  affection  it  may  be  congenital  in  origin  or  appear 
shortly  after  birth,  when  it  is  an  evidence  of  neural  insufficiency. 
It  may  occur  without  any  preceding  disturbance  of  the  optic 
nerves,  as  in  such  diseases  as  locomotor  ataxia,  multiple  sclerosis, 
diabetes,  and  chronic  alcohol  and  tobacco  poisoning  (Fig.  113). 
As  a  secondary  affection  it  may  be  the  terminal  state  of  an  optic 
neuritis  or  of  other  diseased  conditions  of  the  optic  nerve  (Fig. 

114)- 
Symptoms. — Optic  atrophy  evidences  >itself  by  a  gradual  loss 


DISEASES  OF  THE  MOTOR  NERVES  OF  THE  EYE   255 

of  vision.    This  is  accompanied  by  a  progressive  contraction  of 
the  visual  field  and  defective  color  vision. 

Diagnosis  is  made  as  the  result  of  ophthalmoscopic  examina- 
tion, inspection  of  the  fields  of  vision  for  white  and  for  colors, 
etc.  In  optic  atrophy  it  is  important  to  discover  the  imderlying 
cause,  if  one  exists.  The  prognosis  is  very  grave,  and  unless. the 
cause  is  removed  the  condition  is  progressive. 


Fig.  114. — Postneuritic  optic  atrophy. 

Treatment. — Remove  the  cause,  build  up  the  general  health  of 
the  patient,  and  give  strychnin  in  increasing  doses  to  the  physio- 
logic limit. 


DISEASES   OF  THE  MOTOR  NERVES  OF  THE  EYE 

Diseases  of  the  Third  Nerve. — This  nerve  may  be  affected  in 
diseases  involving  the  base  of  the  brain  in  the  middle  fossa,  such 
as  meningitis,  tumors,  abscess,  hemorrhage,  s\'philis,  etc.  It  is 
also  affected  in  diseases  within  the  orbit,  such  as  fractures, 
tumors,  etc.,  and  may  be  involved  as  the  result  of  infectious 
diseases  or  be  one  of  the  evidences  of  chronic  toxemia.  Exposure, 
thrombosis  of  the  cavernous  sinus,  chronic  alcoholism,  toxemia 
caused  by  eating  infected  fish,  meat,  or  sausage,  arteriosclerosis 


256  MANUAL   OF   NERVOUS   DISEASES 

of  the  basal  cranial  vessels,  etc.,  are  all  predisposing  causes. 
Syphilis  is  one  of  the  most  common  causes  of  paralysis  of  the 
third  nerve. 

Symptoms. — As  this  nerve  supplies  the  levator  palpebrae, 
internal  rectus,  superior  rectus,  inferior  rectus,  and  sends 
branches  to  the  ciliary  muscle,  the  symptoms  are  dependent 
upon  the  location  of  the  lesion  affecting  this  nerve.  If  the  nerve- 
stem  is  involved  between  its  point  of  origin  and  its  entrance  into 
the  orbit,  before  dividing  into  its  separate  branches,  -this  is 
evidenced  either  by  weakness  or  by  paralysis  of  all  the  muscles 
supplied  by  this  nerve.  In  this  condition  there  will  exist  a 
ptosis  or  drooping  of  the  upper  eyelid,  inability  to  turn  the  eye- 
ball upward,  downward,  or  inward,  with  loss  of  the  pupillary 
reflex  to  light  and  to  accommodation.  If  the  third  nerve  is 
affected  within  the  orbit,  one  or  more  of  the  branches  may 
escape,  and  the  symptoms  will  then  be  limited  to  the  particular 
branches  involved.  If  the  paralysis  of  the  levator  palpebrae  is 
complete,  so  that  the  patient  is  unable  to  raise  the  upper  eyelid 
sufficiently  to  see,  he  usually  makes  an  extra  effort  to  elevate  the 
upper  eyelid  by  elevating  the  eyebrow,  thus  causing  excessive 
wrinkling  of  the  skin  of  the  forehead. 

The  prognosis  depends  entirely  upon  the  cause.  If  the  con- 
dition is  due  to  syphilis,  exposure  to  cold,  or  occurs  after  in- 
fectious diseases  or  toxemias,  the  prognosis  is  usually  good. 

Treatment. — ^This  consists  in  treating  the  causative  condition 
and  in  administering  strychnin  in  proper  doses. 

Paralysis  of  the  Fourth  Nerve. — ^The  fourth  nerve  supplies  the 
superior  oblique  muscle.  Isolated  paralysis  of  this  nerve  is 
extremely  rare.  The  nerve  is  frequently  affected  along  with  the 
third  nerve,  it  being  commonly  involved  in  the  same  conditions 
that  affect  the  latter  nerve.  When  the  fourth  nerve  is  affected, 
there  is  difficulty  in  rotating  the  eye  upward  and  outward. 

Paralysis  of  the  Sixth  Nerve. — ^The  sixth  nerve  supplies  the 
external  rectus  muscle.  It  pursues  the  longest  course  within  the 
cranial  cavity  of  any  of  the  cranial  nerves,  and  is  frequently 
affected.  The  same  causes  that  bring  about  involvement  of  the 
third  or  fourth  nerve  may  also  affect  the  sixth  nerve. 

Symptoms. — Involvement  of  the  nerve  brings  about  weakness 


DISEASES    OF    THE   MOTOR   NERVES    OF    THE    EYE       257 

or  paralysis  of  the  external  rectus  muscle,  and  this  results  in 
either  partial  or  total  inability  to  rotate  the  eyeball  outward;  as 
a  result,  double  vision  frequently  occurs. 

Ophthalmoplegia. — This  is  a  condition  characterized  by  par- 
tial or  complete  paralysis  of  the  muscles  of  the  eye.  It  may 
result  from  involvement  of  the  peripheral  portions  of  the  third, 
fourth,  and  sixth  nerve,  or  from  involvement  of  the  nuclei  or 
of  the  nerves  in  their  course  from  the  nuclei  to  their  super- 
ficial origin. 

Etiology. — The  disease  may  be  caused  by  exposure  to  cold,  or 
may  follow  or  accompany  infectious  diseases,  diphtheria,  influ- 
enza, tN-phoid  fever,  s>^hilis,  injury,  trauma,  inflammatory  con- 
ditions at  the  base  of  the  brain,  chronic  intoxication,  compres- 
sion by  tumors,  exudates,  or  hemorrhage,  disease  of  the  blood- 
vessels, etc.  It  may  also  occur  as  the  result  of  a  lesion  involving 
the  brain-stem. 

Symptoms. — It  may  come  on  gradually  or  suddenly.  Paral- 
ysis may  be  complete  or  partial,  some  or  all  of  the  muscles  of 
the  eye  being  involved,  or  only  the  internal  muscles  of  the  eye 
may  be  affected,  w^hen  it  is  known  as  internal  ophthalmoplegia. 
When  the  external  muscles  of  the  eye  alone  are  involved,  the 
aft'ection  is  known  as  external  ophthalmoplegia.  It  may  be 
bilateral  or  unilateral,  and  may  occur  as  a  part  of  some  more 
diffuse  process.  The  condition  is  manifested  by  partial  or  com- 
plete immobility  of  the  eyeball  and  upper  eyelid  in  external 
ophthalmoplegia,  and  partial  or  complete  immobility  of  the 
pupil  in  internal  ophthalmoplegia.  When  it  is  due  to  an  in- 
volvement of  the  nuclei,  the  symptoms  are  usually  bilateral; 
w^hen  due  to  involvement  of  the  peripheral  portions  of  the  third, 
fourth,  and  skth  nerve,  the  symptoms  are  dependent  upon  the 
location,  extensiveness,  and  character  of  the  causative  condition. 
Acute  ophthalmoplegia  is,  as  a  rule,  sudden  in  onset,  with 
severe  constitutional  symptoms. 

The  course  of  the  disease  depends  upon  the  causative  con- 
dition; if  this  is  hemorrhage  or  infection,  there  is  usually  a  rapidly 
fatal  termination;  if  due  to  thrombosis  or  edema,  there  is  gener- 
ally some  improvement  at  first,  but  permanent  symptoms  of 
irregular  ocular  paralysis  remain.  The  disease  may  be  chronic 
17 


258  MANUAL   OF  NERVOUS   DISEASES 

in  onset,  beginning  gradually,  one  muscle  after  another  being 
affected.  In  these  cases  the  lesion  is  generally  vascular,  the 
result  of  a  tumor  or  syphilis.  — 

The  prognosis  depends  upon  the  cause:  those  cases  due 
to  exposure,  occurring  after  toxemias,  infectious  diseases,  the 
result  of  syphilis  or  vascular  diseases,  if  not  very  extensive, 
usually  recover;  in  chronic  extensive  cases  the  prognosis  is  very 
unfavorable. 

Treatment. — ^This  should  be  directed  toward  removing  the 
cause.  In  cases  of  acute  onset,  with  fever,  ice-bags  should  be 
applied  to  the  back  of  the  neck  and  over  the  temples,  and  blood- 
letting in  the  temporal  region  and  free  purgation  should  be 
immediately  instituted.  In  the  chronic  conditions  potassium 
iodid  and  strychnin,  in  addition  to  the  treatment  of  the  cause, 
may  be  effective. 

DISEASES   OF  THE  FIFTH  NERVE 

With  the  exception  of  neuralgia,  primary  isolated  diseases  of 
the  fifth  nerve  are  rare.  This  nerve  supplies  sensation  to  the 
face,  to  the  mucous  membrane  of  the  eyes,  nose,  and  mouth,  and, 
through  its  chorda  tympani  branch,  it  supplies  the  sense  of 
taste  to  the  anterior  two- thirds  of  the  tongue. 

Etiology. — This  nerve  may  be  affected  in  morbid  processes 
developing  at  the  base  of  the  brain,  from  the  pons  and  meninges, 
£uch  as  fractures,  inflammation,  and  new-growlhs;  in  diseases  of 
the  sinuses,  syphilis,  and  operations  for  the  removal  of  the 
Gasserian  ganglion;  it  may  be  involved  in  infectious  diseases 
and  toxemias.  In  tetanus  especially  there  is  a  selective  tendency 
toward  involvement  of  this  nerve.  Hemorrhage,  softening, 
tumors,  etc.,  involving  the  pons  also  bring  about  disturbances 
in  the  functions  of  the  fifth  nerve. 

Symptoms. — The  symptoms  pointing  toward  involvement  of 
this  nerve  are  of  two  kinds :  those  due  to  irritation  and  those  due 
to  •  destructive  processes.  As  this  nerve  is  a  mixed  one,  con- 
taining both  sensory  and  motor  filaments,  irritative  conditions 
may  manifest  themselves  along  the  distribution  of  either  the 
sensory  branches  or  the  motor  branches,  or  both.  The  evidences 
of  irritation  of  the  sensory  branches  are  pain  or  paresthesia  in 


DISEASES    OF    THE    SEVENTH    OR   FACIAL   NERVE       259 

Hhe  forehead,  eye,  face,  nose,  mouth,  and  teeth,  depending  upon 
the  extent  of  the  involvement.  Irritation  of  the  motor  portion 
evidences  itself  in  spasmodic  contractions  of  the  muscles  of 
mastication.  Destructive  lesions  of  this  nerve  may  manifest 
themselves  by  loss  of  sensation  in  the  distribution  of  one  or 
more  of  the  branches  of  the  nerve,  with  or  without  paralysis  of 
the  muscles  of  mastication.  In  addition  to  the  motor  and  sen- 
sory functions,  the  fifth  nerv^e  also  transmits  vasomotor  and 
trophic  stimuli.  In  destructive  diseases  of  this  ner\'e  it  is  quite 
common  to  see  ulcerations,  disturbance  of  the  nutrition  of  the 
teeth  and  gums,  disorders  of  the  secretions  of  the  mucous 
membrane  of  the  nose  and  mouth,  herpetic  eruptions,  loss  of 
the  winking  reflex,  and  disturbances  in  the  reflex  secretion  of 
tears,  saliva,  etc. 

Prognosis  and  course  are  dependent  upon  the  causative  con- 
dition. The  treatment  should  be  directed  toward  removal  of 
the  cause. 

DISEASES  OF  THE  SEVENTH  OR  FACIAL  NERVE 
Etiology. — In  about  70  per  cent,  of  cases  of  facial  paralysis 
occurring  in  adults,  in  which  the  peripheral  portion  of  the  nerve 
is  affected,  exposure  to  cold  is  the  cause.  This  rheumatic 
affection  of  the  nerve  is  frequently  combined  with  a  congenital 
smallness  of  the  stylomastoid  foramen.  Disease  of  the  middle 
ear,  with  necrosis  of  the  petrous  portions  of  the  temporal  bones, 
is  an  extremely  frequent  cause  in  infancy  and  childhood.  The 
condition  may  also  follow^  diphtheria,  mumps,  erysipelas,  gout,  or 
diabetes,  and  may  occur  during  the  puerperal  period,  in  injuries, 
such  as  the  application  of  forceps  during  delivers^,  fracture  of  the 
skull,  operations  upon  the  mastoid,  chronic  intoxications, 
s^'philis,  inflammatory  diseases,  new-growths,  and  vascular 
diseases  at  the  base  of  the  brain. 

Diseases  of  the  pons,  medulla,  internal  capsule,  or  lowxr 
portion  of  the  precentral  convolution  may  also  cause  weakness  or 
paialysis  of  the  facial  muscles.  Facial  paralysis  may  be  con- 
genital, in  w^hich  case  it  is  usually  bilateral,  and  associated  with 
paralysis  of  other  cranial  nerves  or  other  anomalies  of  develop- 
ment. 


26o  MANUAL  OF  NERVOUS  DISEASES 

Symptoms.— The  symptoms  of  disease  of  the  seventh  nerve 
are  weakness  and  paralysis  of  the  muscles  of  expression.  The 
type  of  paralysis  may  be  flaccid  or  spastic.  The  extent  of  the 
paralysis  depends  upon  the  severity  and  position  of  the  lesion, 
and  whether  the  nerve  is  affected  externally  to  the  stylomastoid 
foramen,  within  the  Fallopian  canal,  in  its  course  between  the 
medulla  and  internal  auditory  meatus,  where  it  is  in  apposition 
with  the  eighth  nerve ;  in  the  medulla,  where  it  is  in  close  relation- 
ship with  the  nucleus  of  the  sixth;  or  whether  the  disease  is  due  to 
involvement  of  the  lower  precentral  convolution  or  the  tracts  that 
convey  the  impulse  from  this  convolution  to  the  nucleus  (Figs. 
33, 13) •  0^^  the  nerve,  just  before  entering  the  internal  auditory 
foramen,  is  a  small  ganglion — the  geniculate  ganglion.  When  this 
is  involved  along  with  the  nerve,  there  is  usually  pain  in  the  ear 
and  mastoid  region,  and  disturbance  of  sensation  in  the  external 
auditory  meatus,  and  frequently  a  herpetic  eruption  over  the 
tympanum  and  external  auditory  canal  occur.  In  those  cases 
in  which  the  disease  involves  the  nerve  close  to  the  stylomas- 
toid foramen  the  onset  is  more  or  less  acute,  depending  upon  the 
cause.  When  the  condition  follows  chill  or  exposure  it  is  called 
BelVs  paralysis  (Fig.  115).  In  this  form  a  day  or  so  after  ex- 
posure the  patient,  upon  arising,  notices  that  there  is  a  difference 
in  the  appearance  of  the  two  sides  of  the  face.  There  is  little 
or  no  pain,  but  there  may  be  the  general  constitutional  symptoms 
as  in  a  cold.  Depending  upon  the  extent  of  involvement  of  the 
nerve,  the  patient  will  notice  either  a  total  or  a  partial  paralysis 
of  the  muscles  of  the  face.  Thus  on  one  side  there  may  be  a 
flatness,  the  natural  lines  of  the  affected  side  of  the  face  being 
obliterated.  There  is  an  inability  to  wrinkle  the  forehead  and 
to  close  the  eyelids ;  the  reflex  act  of  winking  is  abolished.  The 
patient  is  unable  to  show  the  teeth,  to  whistle,  or  to  perform 
other  voluntary  movements  with  the  affected  side  of  the  face. 
In  chewing,  the  food  collects  between  the  cheek  and  the  gums. 
The  appearance  of  the  face  is  very  characteristic,  and,  owing  to 
the  absence  of  the  reflex  movements  of  the  eyelid,  there  fre- 
quently occurs  a  conjunctivitis  and  tears  run  from  the  corner  of 
the  eye.  In  these  cases  the  paralysis  is  of  a  flaccid  type, 
and  according  to  the  severity  of  the  condition  do  we  have  com- 


DISEASES    OF    THE   SEVENTH    OR   FACIAL  NERVE      26 1 

plete  or  partial  reaction  of  degeneration.  When  the  nerve  is 
affected  within  the  Fallopian  canal,  the  corda  tympani,  which 
accompanies  it  in  this  part  of  its  course,  is  affected,  and,  in 
addition  to  the  foregoing  symptoms,  there  is  disturbance  of  the 
sense  of  taste  over  the  anterior  two-thirds  of  the  tongue  on  the 
affected  side.  When  the  nerve  is  affected  just  internal  to  the 
internal  auditory  meatus  the  geniculate  ganglion  may  be  in- 
volved, in  which  case  there  is  pain  in  the  ear,  sensors'  disturbance 
in  the  external  auditory  canal,  and,  most  probably,  herpetic 
eruptions,  in  addition  to  the  paralytic  symptoms.  W^hen  the 
nerve  is  affected  in  its  course  from  the  medulla  to  the  internal 


Fig.  115. — Bell's  palsy. 

auditory  meatus,  owing  to  the  fact  of  its  close  apposition  to  the 
eighth  nerve,  there  are  nearly  always  auditory  disturbances  added 
to  the  paralytic  symptoms.  If  the  nerv^e,  in  its  course  from  the 
nucleus  to  its  superficial  origin,  or  if  the  nucleus  itself  is  involved, 
owing  to  the  close  anatomic  relationship  of  the  nucleus  of  the 
sixth  to  the  nucleus  of  the  seventh  nerve,  and  to  the  course  of 
fibers  of  the  seventh  from  its  nucleus  to  its  superficial  origin, 
there  is,  in  addition  to  the  paralytic  symptoms  referable  to  the 
seventh,  disturbance  of  the  function  of  the  skth  nerve. 

If  the  facial  paralysis  is  due  to  a  lesion  involving  either  the 
precentral  convolution  or  the  tracts  from  this  convolution  to  the 
nucleus  of  the  seventh  nerve,  the  facial  paralysis  is  never  com- 


262  MANUAL   OF   NERVOUS   DISEASES 

plete — the  forehead  and  the  eyeUds  escape.  The  paralysis  is 
of  the  spastic  type,  and  there  are  no  disturbances  of  the  electric 
reaction.  Rapidity  of  onset  depends  in  large  part  upon  the 
cause,  some  cases  being  comparatively  sudden  and  acute,  whereas 
others  are  very  much  more  chronic.  Bilateral  paralysis  is 
comparatively  rare,  but  may  occur  as  a  congenital  condition, 
as  one  of  the  manifestations  of  a  chronic  toxemia,  or  as  an  evi- 
dence of  disease  of  the  medulla.  It  may  occur  in  rheumatic 
cases,  in  which  one  side  of  the  face  is  affected  after  the  other. 
In  some  instances  but  a  brief  interval  elapses  before  the  two 
sides  are  affected,  and  in  others  there  is  an  indefinite  period, 
the  other  side  of  the  face  being  affected  in  the  individual's 
second  attack. 

The  course  of  this  disease  is  dependent  upon  the  location 
and  severity  of  the  lesion.  In  those  cases  that  are  due  to  su- 
pranuclear diseases,  disease  of  the  nucleus  or  of  the  nerve  within 
the  cranial  cavity  or  the  Fallopian  canal,  the  progress  of  the 
affection  depends  altogether  upon  the  cause,  some  cases  being 
acute,  whereas  others  are  chronic.  In  those  cases  due  to  disease 
of  the  nerve  external  to  the  Fallopian  canal  the  onset  is  usually 
acute,  the  condition  coming  on  within  a  few  hours  or  days, 
reaching  its  greatest  intensity  very  rapidly,  and  then  remaining 
stationary  or  gradually  improving  until  recovery  takes  place. 

Prognosis  is  dependent  entirely  upon  the  cause.  In  those 
cases  in  which  the  nerve  is  affected  external  to  the  stylomastoid 
foramen,  the  prognosis  is  usually  good;  in  those  due  to  diseases 
of  the  nucleus  or  of  the  trunk  of  the  nerve  within  the  cranial 
cavity  or  within  the  Fallopian  canal,  the  prognosis  is  unfavor- 
able. The  electric  examination  of  the  muscles  and  nerve  on  the 
affected  side,  made  about  a  week  after  the  occurrence  of  the 
affection,  is  of  the  greatest  assistance  in  making  a  prognosis.  If 
the  cause  can  be  removed  and  the  patient  has  normal  electric 
reaction,  recovery  will  take  place  within  six  weeks;  if  the  cause 
can  be  removed  and  the  patient  has  a  partial  reaction  of  degener- 
ation, recovery  will  take  place  within  six  months;  if  the  cause  can 
be  removed  and  the  patient  has  a  complete  reaction  of  degener- 
ation, the  probabilities  are  that  complete  recovery  will  take  place 
in  from  nine  to  eighteen  months.     Following  recovery  there 


DISORDERS    OF    THE    EIGHTH    OR   AUDITORY    NERVE      263 

develop  in  some  cases  contractures  of  the  affected  muscles, 
which  cause  the  face  to  appear  as  if  there  was  a  paralysis  on 
the  opposite  side. 

Treatment. — If  possible,  remove  the  cause.  In  those  cases  in 
which  the  condition  is  due  to  exposure,  if  the  patient  is  seen 
within  one  or  two  days  after  the  occurrence  of  the  paralysis,  it 
is  well  to  apply  a  blister  over  the  lower  mastoid  region.  Inter- 
nally, salicylates  or  aspirin  in  proper  doses  are  indicated.  Pro- 
mote free  elimination  by  the  skin,  kidneys,  and  intestines; 
keep  the  patient  warm,  and  avoid  all  exposure.  This  treatment 
should  be  persisted  in  for  about  a  week,  after  which  measures 
should  be  taken  to  promote  regeneration  of  the  ner\'e,  to  main- 
tain the  nourishment  of  the  muscles,  and  to  prevent  the  develop- 
ment of  unpleasant  complications.  Internally,  strychnin  in 
proper  doses  and  small  doses  of  potassium  iodid  or  ferrous 
iodid  should  now  be  given.  Electricity  should  be  used  daily, 
using  that  form  of  current  which  will  bring  about  muscle  con- 
traction. Massage,  properly  applied,  is  also  very  useful.  As 
the  patient  improves  electric  treatment  and  massage  may  be 
given  less  frequently.  Proper  protection  of  the  conjunctiva 
of  the  affected  eye  wall  prevent  the  development  of  disagreeable 
complications.  Contractions,  if  they  develop,  may  be  relieved 
by  warm  applications  and  massage.  In  those  cases  that  show 
no  tendency  to  recover  after  eighteen  or  twenty-four  months 
surgical  treatment  may  be  resorted  to. 

DISORDERS   OF  THE  EIGHTH   OR  AUDITORY  NERVE 

The  eighth  nerve  is  a  sensory  nerve  and  has  two  distinct 
functions:  it  transmits  impulses  that  result  in  hearing,  and  it 
transmits  impulses  that  are  concerned  wdth  equilibrium. 

Etiology. — ^The  nerve  may  be  affected  in  such  diseases  as 
locomotor  ataxia,  multiple  sclerosis,  etc.;  in  tumors,  in  inflam- 
matory conditions,  in  diseases  of  the  blood-vessels  and  bones, 
and  in  injuries  at  the  base  of  the  brain;  in  s}^hilis,  in  marked 
anemic  conditions,  following  exposure,  in  chronic  intoxications, 
and  in  disease  of  the  middle  ear  or  labyrinth,  etc. 

Symptoms. — The  s\Tnptoms  of  disturbance  of  function  of 
this  nerve  or  its  branches  are  defective  hearing,  unstable  equi- 


264  MANUAL   OF  NERVOUS   DISEASES 

librium,  vertigo,  and  tinnitus  aurium.  There  may  be  complete 
or  partial  deafness,  caused  either  by  diseases  of  the  nerve  itself  or 
by  diseases  of  the  ear. 

Tinnitus  aurium  is  a  condition  characterized  by  subjective 
sounds  that  apparently  occur  within  the  ear,  as  ringing,  roar- 
ing, throbbing,  etc.  These  sounds  are  due  to  irritation  of 
the  auditory  nerve  or  auditory  organs,  and  may  be  due  to 
disease  of  the  blood-vessels,  disturbance  of  circulation,  anemic 
or  gouty  conditions,  diseases  of  the  middle  and  external  ear, 
conditions  that  interfere  with  the  circulation  of  air  in  the 
external  auditory  canal,  drugs,  especially  quinin,  diseases  of 
the  throat  and  nose,  general  malnutrition,  hysteric  and  neuras- 
thenic states,  long-continued  subjection  to  loud  noises,  etc. 

The  disturbance  of  equilibrium  and  the  vertigo  may  be  due 
to  diseases  of  the  eighth  nerve  or  of  the  semicircular  canal.  In 
addition  to  disorders  of  the  eighth  nerve  or  of  its  end-organs, 
there  are  many  other  conditions  in  which  disturbance  of  equi- 
librium and  vertigo  occur,  but  these  are  not,  as  a  rule,  attended 
by  derangements  of  hearing. 

Prognosis. — The  prognosis  of  disease  of  the  eighth  nerve 
depends  entirely  upon  the  cause. 

Diagnosis. — Isolated  involvement  of  the  eighth  nerve  is  rare 
compared  with  the  frequency  of  ear  diseases.  Careful  examina- 
tion usually  enables  one  to  distinguish  between  these  conditions. 
The  occurrence  of  symptoms  indicating  involvement  of  other 
structures  of  the  body  or  of  other  nerves  enables  one  to  locate 
the  site  of  the  disease.  Toxic  and  infectious  acoustic  neuritis 
is  characterized  by  deafness,  which  is  generally  bilateral,  coming 
on  with  loud  and  usually  constant  tinnitus  aurium. 

Treatment. — This  consists  in  treating  and  removing  the 
cause. 

DISEASES  OF  THE  NINTH  OR  GLOSSOPHARYNGEAL  NERVE 

This  nerve  supplies  sensation  to  the  pharynx  and  the  tympanic 
cavity,  and  the  sense  of  taste  to  the  posterior  part  of  the  tongue. 
It  also  contains  some  motor  filaments  which,  in  common  w4th 
those  of  the  pneumogastric,  arise  from  the  nucleus  ambiguus. 


THE    TENTH,    PNEUMOGASTRIC,    OR   VAGUS    NERVE      265 

Etiology. — The  ninth  nerve  may  be  affected  in  syphilitic 
conditions,  in  inflammatory  processes,  tumors,  fractures  affect- 
ing the  posterior  fossa,  disease  of  the  jugular  vein,  tumors  and 
injuries  of  the  neck,  diseases  of  the  medulla,  etc.  It  may  also 
be  involved  as  the  result  of  infectious  diseases,  such  as  diph- 
theria, and  in  chronic  intoxication. 

Symptoms. — Isolated  paralysis  of  this  nerv^e  is  practically 
never  observed.  When  the  ner\^e  is  affected  along  with  other 
nerves,  the  symptoms  consist  of  anesthesia  in  the  upper  part  of 
the  pharynx,  loss  of  taste  in  the  posterior  part  of  the  tongue, 
difficulty  in  swallowing,  regurgitation  of  food  through  the  nose, 
loss  of  the  pharyngeal  reflex,  and  paralysis  of  some  of  the  muscles 
of  the  palate. 

Prognosis  and  treatment  are  those  of  the  causative  condition. 

THE  TENTH,  PNEUMOGASTRIC,  OR  VAGUS  NERVE 

This  nerve  has  both  sensory  and  motor  fibers.  Its  motor 
fibers  arise  from  the  nucleus  ambiguus,  in  common  with  those 
of  the  ninth  nerv^e.  This  nerve  is  also  closely  connected  with 
the  s\TQpathetic  system.  It  pursues  a  very  long  course  and  has 
an  extensive  distribution.  In  conjunction  with  the  glosso- 
pharyngeal nerve,  it  is  distributed  to  the  muscles  of  the  pharynx, 
lar3nix,  and  esophagus;  it  is  also  distributed  to  the  heart,  lungs, 
stomach,  etc.  In  addition  to  its  sensory  and  motor  functions, 
it  has  vasomotor  and  secretory  fibers. 

Etiology. — This  nerve  may  be  affected  by  trauma  at  any  part 
of  its  course,  inflammatory  conditions  in  the  neighborhood  of  the 
ner\'e.  It  is  also  affected  following  infectious  conditions,  especially 
diphtheria,  and  in  chronic  intoxication,  diseases  at  the  base  of  the 
brain  in  the  posterior  cranial  fossa,  such  as  meningitis,  tumors, 
hemorrhages,  and  vascular  diseases.  Diseases  in  the  medi- 
astinum, such  as  aneurysms  and  inflammatory  conditions; 
operations  on  the  neck,  chest,  or  posterior  cranial  fossa;  diseases 
of  the  medulla,  such  as  bulbar  paralysis;  syphilis;  drugs,  such 
as  atropin,  aconite,  etc. 

Symptoms. — These  depend  upon  the  extent  and  the  site  of 
the  lesion.  If  the  lesion  is  limited  to  one  side,  then  unilateral 
paralysis  of  the  palate,  larynx,  and  pharynx  is  the  prominent 


266  MANUAL   OF   NERVOUS   DISEASES 

symptom.  Sensory  disturbances  are  rarely  found.  If  the 
nerve  is  affected  outside  of  the  cranial  cavity,  unless  the  lesion 
occurs  very  high  in  the  neck,  there  is,  as  a  rule,  little  or  no 
disturbance  of  deglutition.  The  symptoms  arising  from  the 
heart  are  variable — sometimes  there  is  a  slowing  and  sometimes 
there  is  an  acceleration  of  the  heart  action. 

There  are  usually  no  respiratory  disturbances,  except  in  so 
far  as  the  laryngeal  involvement  may  interfere  with  respiration. 

The  most  important  symptom  of  unilateral  involvement  of 
the  tenth  nerve  is  laryngeal  paralysis.  This  is  characterized 
by  paralysis  of  a  vocal  cord,  which  remains  immovable  during 
phonation  and  respiration.  The  voice  is  usually  somewhat 
hoarse,  and  deep  inspriation  is,  as  a  rule,  accompanied  by 
stridor.  In  bilateral  paralysis  the  symptoms  are  very  much 
more  severe.  This  is  generally  the  result  of  nuclear  involve- 
ment. The  symptoms  in  this  condition  are  marked  respiratory 
and  cardiac  disturbances,  paralysis  of  the  muscles  of  the  pharynx, 
soft  palate,  and  larynx,  giving  rise  to  disturbances  of  swallowing, 
marked  interference  with  phonation,  hoarse,  stridulous  breath- 
ing, shortness  of  breath,  inability  to  cough,  etc. 

Among  the  more  important  branches  of  the  tenth  nerve  are 
those  that  go  to  the  muscles  of  the  larynx ;  these  are  the  recurrent 
laryngeals.  When  either  or  both  are  involved,  marked  symp- 
toms occur.  The  recurrent  laryngeal  may  be  involved  in 
diseases  of  or  in  operations  on  the  thyroid  gland;  in  diseases  in 
the  mediastinum,  such  as  tumor  or  aneurysms,  etc. ;  in  intoxica- 
tions and  in  infectious  diseases,  etc.  The  symptoms  of  involve- 
ment of  these  nerves  are  paralysis  or  weakness  of  the  muscles  of 
the  larynx,  resulting  in  disturbances  of  phonation  and  respiration. 

Diagnosis. — The  diagnosis  of  unilateral  disease  of  the  pneu- 
mogastric  nerve  is  very  difficult  unless  involvement  of  its 
recurrent  laryngeal  branch  has  taken  place.  The  diagnosis  of 
bilateral  involvement  of  the  nerve  is  made  from  disturbances 
in  swallowing,  in  respiration,  and  in  phonation.  The  diagnosis 
of  the  causative  condition  is  made  as  the  result  of  a  careful  con- 
sideration of  the  history,  the  course  of  the  disease,  the  symptoms, 
and  the  presence  of  symptoms  pointing  to  involvement  of  other 
structures. 


DISEASE    OF    THE    TWELFTH    OR   HYPOGLOSSAL    NERVE       267 

The  prognosis  of  the  condition  is  very  grave,  but  depends 
entirely  upon  the  cause. 

Treatment. — This  consists  in  treating  or  removing  the  cause. 
Careful  nursing,  the  prevention  of  pulmonary  complications, 
and  stimulation  if  necessary. 

DISEASE   OF  THE  ELEVENTH  OR  SPINAL  ACCESSORY 

NERVE 

This  nerve  innervates  the  sternomastoid  and  part  of  the 
trapezius  muscle. 

Etiology. — This  ner\^e-  may  be  involved  in  diseases  of  the 
upper  cervical  segments  of  the  spinal  cord;  diseases  of  the 
upper  cervical  vertebrae;  syphilis,  tuberculosis,  meningitis,  tu- 
mors, etc.,  in  the  posterior  cranial  fossa;  injuries,  inflammatory 
conditions,  and  tumors  in  the  upper  part  of  the  neck;  exposure 
to  cold,  and  rarely  toxic  conditions. 

Symptoms. — Paralysis  or  weakness  of  the  sternomastoid  and 
trapezius ;  this  paralysis  is  flaccid  in  t>^e,  and  there  is  complete 
or  partial  reaction  of  degeneration.  The  paralysis  of  these 
muscles  gives  rise  to  interference  in  the  turning  of  the  head,  the 
touching  of  the  chin  to  the  shoulder,  and  the  elevation  of  the 
arm  above  the  horizontal  line. 

The  course  of  the  condition  depends  entirely  upon  the  cause, 
and  the  prognosis  is  dependent  upon  the  possibility  of  removal 
of  the  cause. 

Treatment. — Remove  the  cause  if  possible;  use  massage  and 
electricity;  prevent  deformity  by  applying  appropriate  appara- 
tus. Surgical  treatment  is  indicated  in  those  cases  in  which  it 
offers  a  chance  for  improvement. 

DISEASE  OF  THE  TWELFTH   OR   HYPOGLOSSAL   NERVE 

This  nerve  is  distributed  to  the  muscles  of  the  tongue. 

Etiology. — This  nerve  is  much  more  frequently  affected  by 
disease  within  the  cranial  cavity  than  in  its  course  outside  of  the 
skull.  Diseases  of  the  medulla,  such  as  hemorrhage;  bulbar 
paralysis;  vascular  disease;  diseases  in  the  posterior  fossa,  such 
as  tumors,  hemorrhages,  aneurysms,  fractures,  necrosis  of  the 


268  MANUAL   OF   NERVOUS   DISEASES 

bone,  syphilis,  diseases  in  the  upper  part  of  the  neck,  such  as 
injury,  tumors,  etc.,  are  factors  in  the  etiology.  The  nerve  may 
also  rarely  be  involved  in  such  diseases  as  locomotor  ataxia, 
multiple  sclerosis,  etc.;  it  is  very  rarely  involved  in  chronic 
intoxications  and  infectious  processes. 

Symptoms. — If  only  one  nerve  is  affected,  that  side  of  the 
tongue  will  present  a  flaccid  paralysis,  and  there  will  be  atrophy 
of  half  the  tongue.  If  an  effort  is  made  to  protrude  the  tongue, 
it  will  deviate  toward  the  paralyzed  side.  Electric  exam- 
ination shows  partial  or  complete  reaction  of  degeneration. 
There  is  little  or  no  disturbance  of  mastication  and  deglutition, 
but  some  disturbance  of  articulation.  In  bilateral  involve- 
ment of  the  twelfth  nerve  there  is  inability  to  protrude  the 
tongue, — it  remains  motionless  in  t"he  mouth, — and  atrophy 
and  marked  interference  with  mastication,  deglutition,  and 
articulation  occur.  In  nuclear  involvement  there  is  usually 
also  paralysis  or  weakness  of  the  lips,  with  atrophy  of  the 
orbicularis  muscle. 

The  prognosis  and  course  depend  upon  the  cause. 

Treatment. — Remove  or  treat  the  cause. 

DISEASES   OF  THE   CRURA,  PONS,  AND   MEDULLA 

In  the  portion  of  the  nervous  system  occupied  by  the  crura, 
pons,  and  medulla  there  are  grouped,  in  a  very  small  area, 
many  important  nervous  structures.  Passing  down  through 
the  anterior  portion  of  these  structures  are  the  pathways  for  the 
conduction  of  stimuli  that  result  in  voluntary  movements;  in 
the  posterior  and  lateral  portion  are  the  pathways  that  transmit 
upward  the  stimuli  that  are  perceived  as  the  various  forms  of 
sensation,  and  those  stimuli  that  result  in  the  maintenance  of 
equilibrium.  Situated  at  various  levels  are  the  cranial  nerves — 
their  superficial  origin  and  their  nuclei.  On  the  anterior  aspect 
of  these  structures  are  the  vertebral,  basilar,  posterior  communi- 
cating, carotids,  anterior  cerebral  arteries  and  their  branches. 

Etiology. — Disease  of  this  portion  of  the  nervous  system  may 
be  hereditary  in  character.  It  may  also  be  caused  by  diseases 
of  the  vascular  system,  hemorrhage,  more  frequently  softening 


DISEASES    OF   THE    CRURA,    PONS,    AND   MEDULLA       269 

the  result  of  thrombosis,  or  rarely  embolism;  aneurysm  of  the 
vertebral,  basilar,  or  other  vessels  may  compress  these  structures. 
Tumors  in  the  posterior  or  middle  fossa  of  the  skull;  an  acute  or 
subacute  inflammatory  condition  that  may  be  limited  to  the 
gray  matter  or  affect  the  meninges,  etc.;  s^'philis,  leukemia; 
trauma;  such  diseases  as  amyotrophic  lateral  sclerosis,  multiple 
sclerosis,  locomotor  ataxia,  etc.,  are  also  among  the  causes  of 
the  condition. 

Symptoms. — The  symptoms  of  involvement  of  the  medulla, 
pons,  or  crura  depend  upon  the  location,  the  extent,  and  the 
character  of  the  lesion.  A  thorough  knowledge  of  the  anatomy 
and  physiology  of  these  parts  is  absolutely  essential.  (See 
Fig.  32.) 

In  those  cases  in  which  the  condition  is  due  to  tumors  the 
onset  is  usually  more  or  less  gradual,  and  is  accompanied  by 
symptoms  of  an  intracranial  tumor,  e.  g.,  headache,  vomiting, 
etc.  If  the  disease  is  due  to  a  vascular  lesion,  the  onset  may 
be  acute,  subacute,  or  gradual.  In  these  cases  prodromal 
symptoms  generally  occur  that  are  caused  directly  by  the 
vascular  disease.  Thus  an  attack  is  frequently  preceded  by  a 
feeling  of  pressure  in  the  head,  vertigo,  insomnia,  tinnitus 
aurium,  etc.  The  paralysis  then  comes  on  suddenly,  and  there 
may  or  may  not  be  complete  loss  of  consciousness,  or  very 
severe  vertigo  or  con\nilsive  seizures  may  occur.  The  distri- 
bution of  the  paralysis,  the  ataxia,  and  the  sensory  disturbance, 
etc.,  depend  upon  the  location  of  the  lesion.  Those  cases  due 
to  an  inflammatory  condition,  or  in  which  the  bulbar  symptoms 
are  only  a  part  of  the  general  disease,  are  apt  to  have  a  slower 
onset,  depending  upon  the  location  of  the  lesion. 

There  is  generally  weakness  or  paralysis  of  one  side  of  the 
body,  wuth  involvement  of  the  cranial  nerves  upon  the  opposite 
side,  giving  rise  to  crossed  paralysis.  If  the  lesion  is  in  the  crura, 
the  ocular  muscles  of  one  side  are  affected,  and  the  face,  arm, 
and  leg  upon  the  opposite  side  (Weber's  syndrome)  are  also 
involved.  If  the  attack  is  accompanied  by  tremor  of  the  par- 
alyzed limbs,  it  is  called  Benedikt's  syndrome.  If  the  affection 
is  in  the  pons,  the  functions  of  the  fifth  ner\^e  upon  one  side  of 
the  body  and  the  arm  and  leg  upon  the  opposite  side  are  af- 


270  MANUAL   OF   NERVOUS   DISEASES 

fected.  If  the  lesion  is  in  the  medulla,  the  functions  of  the 
sixth,  seventh,  and  eighth  nerves  upon  one  side,  and  the  arm 
and  leg  upon  the  opposite  side,  of  the  body  are  affected — Mil- 
lard-Gubler syndrome.  If  the  lesion  is  more  centrally  situated, 
there  may  be  a  bilateral  involvement  of  the  structures,  with 
disturbance  of  the  functions  of  both  sides  of  the  body  and 
of  the  cranial  nerves  corresponding  to  the  level  of  the  lesion. 
In  the  majority  of  -cases,  in  addition  to  the  bulbar  paralysis, 
there  is  also  a  weakness  or  paralysis  of  the  arm  and  leg  on  the 
opposite  side  to  that  on  which  the  paralysis  of  the  bulbar 
nerves  is  more  marked,  or,  in  the  more  severe  cases,  a  paraly- 
sis or  weakness  of  both  sides  of  the  body.  The  paralysis  of 
the  extremities  is  spastic  in  nature,  with  an  exaggeration  of 
the  tendon-reflexes.  Respiratory  disturbances,  increase  in 
pulse-rate,  and  rise  in  body  temperature  are  not  unusual.  In 
fatal  cases  these  symptoms  become  more  marked  as  the  end 
approaches.  Patients  suffering  from  disease  of  these  structures 
are  usually  very  emotional. 

Sensory  disturbances  may  occur  if  the  lateral  and  posterior 
columns  of  the  medulla,  pons,  and  crura  are  involved. 

In  those  cases  due  to  occlusion  or  rupture  of  the  posterior 
inferior  cerebellar  artery  the  affected  area  lies  in  the  lateral 
portion  of  the  medulla  and  involves  the  restiform  body,  the 
motor  nucleus  of  the  ninth  and  tenth,  the  descending  root  of  the 
fifth,  part  of  the  reticular  formation,  and  sometimes  the  olivary 
body  and  a  portion  of  the  cerebellum.  The  clinical  symptoms 
consist  of  unilateral  paralysis  of  the  palate  and  larynx,  dif- 
ficulty in  swallowing,  loss  of  pain  and  temperature  sense  in 
a  portion  of  or  the  entire  distribution  of  the  fifth  nerve  on 
the  side  of  the  lesion,  and  a  corresponding  loss  of  pain  and 
temperature  sense,  from  the  face  downward,  upon  the  opposite 
half  of  the  body.  On  the  side  of  the  body  on  which  these 
sensory  disturbances  occur  tactile  sense,  deep  pressure  sense, 
and  muscular  sense  are  generally  intact.  In  some  cases  there  is 
also  an  ataxia  of  the  arm  and  leg  of  the  same  side.  The  onset 
of  this  condition  is  sudden,  attended  with  giddiness  or  vertigo, 
a  tendency  to  fall  to  one  side,  and  frequently  nystagmus. 
Consciousness  is  usually  not  disturbed.    There  may  be  retrac- 


DISEASES    OF    THE    CRURA,    PONS,    AND    MEDULLA       27 1 

tion  of  the  eyeball,  drooping  of  the  eyelid,  and  contraction  of 
the  pupil. 

Diagnosis. — Diseases  involving  the  brain-stem  must  be 
differentiated  from  diseases  of  the  hemispheres  and  from  more 
diffuse  conditions  in  which  the  involvement  of  the  brain-stem  is 
but  a  part  of  the  disease.  The  character  and  the  location  of 
the  lesion  must  also  be  determined.  Diseases  that  are  confined 
to  the  brain-stem  are  differentiated  from  diseases  involving  the 
hemispheres  by  the  fact  that  if  conduction  pathways  are  affected 
in  brain-stem  conditions,  a  crossed  paralysis  occurs;  that  is,  the 
cranial  nerves  are  affected  on  one  side  of  the  body,  and  the  arm 
and  leg  upon  the  opposite  side  of  the  body.  Also  in  brain- 
stem involvement  the  cranial  ner\^e  palsy  is  flaccid,  whereas 
that  due  to  involvement  of  the  hemisphere  is  of  a  spastic 
nature. 

In  lesions  of  the  hemispheres  causing  paralysis  the  eyes  are 
turned  toward  the  non-paralyzed  side;  in  brain-stem  lesions  the 
eyes  are  turned  toward  the  paralyzed  side.  In  irritative  lesions 
of  the  hemispheres  the  eyes  are  turned  toward  the  affected  side; 
in  brain-stem  conditions  the  eyes  are  turned  toward  the  unaf- 
fected side. 

The  Character  of  the  Lesion. — ^Timiors  usually  cause  symptoms 
that  come  on  gradually  and  give  rise  to  both  general  and  focal 
S3anptoms.  The  general  s}Tnptoms  are  those  of  cerebral  tumors, 
that  is,  headache,  vomiting,  vertigo,  optic  neuritis,  etc.;  the 
focal  symptoms  are  those  caused  by  pressure  upon  the  cranial 
nerves  and  the  conduction  pathways,  causing  a  crossed  paralysis. 
It  is  also  important  to  determine  whether  the  tumor  is  situated 
within  the  substance  of  the  brain-stem  or  whether  it  is  situated 
externally.  Tumors  within  the  substance  of  the  brain-stem 
generally  occasion  bilateral  symptoms  of  a  motor  and  sensory 
nature,  with  bilateral  involvement  of  the  cranial  ner^xs  which 
originate  in  the  neighborhood  of  the  tumor.  There  may  be  a 
predominance  of  s}Tnptoms  on  the  side  of  the  tumor,  with  more 
marked  evidence  of  motor  and  sensory  symptoms  upon  the 
opposite  side. 

In  tumors  situated  external  to  the  brain-stem  the  course  is 
slowly  progressive,  beginning  with  symptoms  that  point  to  a 


272 


MANUAL   OF  NERVOUS  DISEASES 


very  limited  involvement  of  the  brain-stem,  and  that  gradually 
progress  and  give  rise  to  the  characteristic  crossed  paralysis 
(Fig.  116).  If  the  tumor  is  situated  in  the  middle  line,  it  is 
practically  impossible  to  distinguish  it  from  a  tumor  situated 
within  the  substance  of  the  brain-stem. 


Fig.  116. — Tumor  of  the  cerebellopontile  angle. 


Vascular  diseases  are  more  or  less  sudden  in  their  onset;  thus 
hemorrhage  and  emboli  appear  suddenly,  whereas  thrombosis 
occurs  more  gradually.  When  the  condition  is  due  to  a 
thrombosis,  the  prodromal  symptoms  generally  occur  that  are 
indicative  of  disease  of  the  cerebral  vessels.     The  attack  itself 


DISEASES    OF    THE    CRURA,    PONS,    AND    MEDULLA       273 

is  usually  preceded  by  paresthesia  in  the  limbs  about  to  be 
affected,  the  paralytic  symptoms  then  appearing  gradually. 

If  the  condition  is  due  to  an  aneurysm,  the  symptoms  of  vas- 
cular disease  occur  along  with  symptoms  that  are  similar  to 
those  occasioned  by  a  tumor. 

If  the  symptoms  pointing  to  brain-stem  involvement  are  but 
a  part  of  the  manifestation  of  a  more  diffuse  disease,  there 
usually  occur  other  symptoms  that  render  the  recognition  of  the 
underlying  disease  possible.  In  all  cases  the  Wassermann  test 
of  the  blood  and  spinal  fluid  and  a  careful  blood  and  urine  ex- 
amination should  be  made. 

The  location  of  the  lesion  is  determined  by  the  symptoms. 
Lesions  in  the  crura  and  upper  pons  generally  involve  the  third 
and  fourth  nerves;  lesions  in  the  pons  and  upper  medulla  in- 
volve the  skth  and  seventh  nerves;  those  in  the  lower  medulla, 
the  ninth,  tenth,  eleventh,  or  twelfth  nerves.  In  addition  to  the 
cranial  nerve  involvement,  depending  upon  the  extent  of  the 
lesion  there  will  also  be  involvement  of  the  conducting  pathways: 
if  the  lesion  is  situated  anteriorly,  the  motor  pathway  is  involved; 
if  the  lesion  is  situated  somewhat  more  posteriorly,  sensory 
pathw^ays  will  be  involved ;  and  if  the  lesion  is  situated  still  more 
posteriorly,  the  pathways  of  coordination  and  equilibrium  are 
affected.  If  the  lesion  is  limited  to  one  side  of  the  brain-stem, 
the  cranial  nerves  on  the  same  side  and  the  extremities  upon  the 
opposite  side  are  affected.  If  the  lesion  is  centrally  placed  and 
is  large  enough,  the  cranial  nerv^es  on  both  sides,  originating  in 
the  location  of  the  lesion,  are  affected,  and  according  to  the  size 
of  the  lesion  there  will  occur  disturbance  of  motion,  sensation, 
etc.,  in  parts  of  the  body  below  the  lesion. 

The  course  and  prognosis  of  these  affections  depend  upon  the 
cause:  in  those  cases  due  to  compression  by  tumors,  aneurysm, 
etc.,  the  course  is  generally  progressive,  and  unless  the  condition 
can  be  relieved  by  surgical  or  medical  treatment,  the  prognosis 
is  unfavorable.  In  those  cases  due  to  rupture  or  occlusion  of 
the  vessels  the  course  and  prognosis  depend  upon  the  severity  of 
the  symptoms.  With  the  exception  of  those  cases  in  w^hich 
death  occurs  within  a  few  days  from  bronchopneumonia  and 
paralysis  of  respiration  and  of  the  heart,  the  course  is  usually 
18 


274  MANUAL   OF   NERVOUS   DISEASES 

regressive — the  symptoms  having  reached  their  greatest  in- 
tensity at  the  onset  of  the  disease,  gradual  improvement  takes 
place  that  may  end  in  recovery.  In  nearly  all  cases  there  are 
residual  symptoms.  The  prognosis  of  diseases  of  the  medulla 
is,  as  a  rule,  very  serious,  for,  in  addition  to  other  dangers,  there 
seems  to  be  an  unusual  susceptibility  to  pneumonia. 

Treatment. — ^The  cause  should  be  sought  and  treated.  If 
there  is  the  slightest  suspicion  that  syphilis  is  at  the  base  of  the 
condition,  antiluetic  measures  should  be  instituted.  In  those 
cases  that  are  due  to  vascular  disturbances  the  patient  is  to  be 
placed  at  absolute  rest ;  if  the  blood-pressure  is  low,  it  is  advisable 
to  administer  strychnin ;  if  the  blood-pressure  is  high,  the  patient 
should  be  freely  purged  and  ice-bags  applied  to  the  neck  in  the 
suboccipital  region.  In  those  cases  due  to  inflammatory  con- 
ditions counterirritation  and  cold  applications  to  the  suboccipital 
region,  free  purgation,  and  free  elimination  by  the  skin  and 
kidneys  are  to  be  encouraged,  and  the  patient  is  to  be  kept 
absolutely  quiet.  In  all  these  cases  careful  attention  must  be 
given  to  the  diet,  for,  owing  to  the  difficulty  in  swallowing  and 
the  loss  of  laryngeal  and  pharyngeal  reflexes,  there  is  great 
danger  of  food  passing  into  the  bronchi.  In  some  cases  it  is  not 
only  advisable,  but  absolutely  necessary,  to  use  a  feeding-tube. 

PROGRESSIVE   BULBAR  PARALYSIS 

This  condition,  which  is  also  known  as  gloss olahiopharyngeal 
paralysis,  is  a  chronic  progressive  disease  involving  the  nuclei  of 
the  motor  cranial  nerves,  usually  beginning  with  the  twelfth, 
and  slowly  progressing  upward  and  involving  the  nuclei  on  both 
sides  of  the  medulla.  In  very  rare  cases  it  begins  high  up  in  the 
pons  or  medulla,  and  proceeds  downward.  In  some  cases  the 
bulbar  symptoms  are  a  part  of  a  more  wide-spread  affection, 
such  as  amyotrophic  lateral  sclerosis,  multiple  sclerosis,  etc. 

Etiology. — ^The  cause  of  this  disease  is  unknown.  In  some 
cases  it  occurs  in  early  life,  when  it  is  usually  a  congenital  con- 
dition, affecting  several  members  of  a  family.  It  generally 
appears  between  the  thirtieth  and  the  sktieth  year,  although  no 
age  is  exempt.  Injury,  emotional  disturbances,  overwork  of 
the  muscles  of  the  tongue,  lips,  and  palate,  such  as  occurs  in 


PROGRESSIVE    BULBAR   PARALYSIS  275 

individuals  who  play  on  wind-instruments^  glass-blowers,  etc.; 
exposure  to  cold;  chronic  lead-poisoning,  etc.,  have  all  been  held 
responsible  for  this  disease. 

Pathology. — There  is  a  progressive  atrophy  of  the  motor 
neurons,  involving  the  nuclei  of  the  twelfth  and  the  eleventh, 
tenth,  ninth,  seventh,  fifth,  and  sometimes  of  the  sixth  and 
third  nerves.  In  addition  to  degeneration  of  the  motor  cells 
and  their  processes,  there  also  occur  atrophy  and  degeneration 
of  the  muscles  with  which  these  cells  are  connected. 

Symptoms. — The  disease  usually  first  manifests  itself  by  diffi- 
culty in  speech,  the  articulation  of  words  containing  the  linguals 
being  interfered  with.  As  the  disease  progresses  this  difficulty 
in  speech  increases,  until  finally  it  is  almost  impossible  to  under- 
stand these  patients.  With  the  progress  of  the  speech  dis- 
turbances there  may  be  noticed  fibillary  tremors  in  the  tongue, 
lips,  pharynx,  etc. ;  these  are  later  followed  by  atrophy  of  the 
affected  structures.  At  first  the  patient's  speech  difficulty 
manifests  itself  only  after  prolonged  conversation,  but  later  it 
is  constantly  present.  Disturbances  of  the  acts  of  chewing  and 
swallowing  are  also  observed.  The  patient  finds  it  difficult  to 
pass  the  food  from  the  mouth  into  the  phar}^nx  with  his  tongue ; 
it  is  also  noticed  that  fluids  regurgitate  into  the  nose  or  pass  into 
the  larynx,  bringing  on  fits  of  coughing.  Finally,  there  is  com- 
plete inability  to  swallow  solid  or  liquid  foods.  Later  on  the 
muscles  of  mastication  become  affected,  and  the  lower  jaw  is 
not  held  in  apposition  with  the  upper,  and  the  mouth  remains 
open.     Eventually  the  mastication  of  food  becomes  impossible. 

When  the  facial  muscles  are  involved,  there  is  an  absence  of 
facial  expression  and  the  facial  folds  become  obliterated;  the 
lower  lip  hangs  down,  and  there  is  more  or  less  constant  dribbling 
of  saliva.  Phonation  and  respiration  finally  become  involved, 
and  the  voice  is  weak  and  monotonous  and  without  modulation. 
Toward  the  end  of  life  respiration  becomes  difficult  and  irregular, 
and  attacks  of  suffocation  occur.  Physical  examination  dis- 
closes weakness  or  paralysis  of  the  tongue,  facial  muscles,  etc., 
which  is  followed  b}^  fibrillary  tremors  and  atrophy.  The 
pharvmgeal  and  laryngeal  reflexes  are  usually  absent.  Laryn- 
goscopic  examination  shows  at  first  weakness  of  the  adductors, 


276  MANUAL   or   NERVOUS   DISEASES 

which  later  become  paralyzed.  In  this  disease  the  weakness  of 
the  muscles  always  precedes  the  appearance  of  the  atrophy. 
Electric  examination  reveals  a  partial  reaction  of  degeneration, 
which  usually  becomes  complete  only  in  the  later  stages  of  the 
disease.  It  is  only  in  very  exceptional  cases  that  the  paralysis 
advances  to  the  ocular  muscles.  These  patients  are,  as  a  rule, 
very  emotional;  they  emaciate  rapidly,  this  probably  being  due 
to  the  interference  with  nutrition. 

Course. — The  disease  usually  advances  slowly  over  a  period 
lasting  from  one  to  three  or  four  years.  During  this  time 
remissions  may  ocur,  but  these  are  generally  of  short  duration. 

The  prognosis  is  extremely  grave,  the  patient  succumbing  to 
inanition,  bronchopneumonia,  asphyxia,  or  some  intercurrent 
disease. 

The  diagnosis  usually  presents  no  difficulty.  The  disease 
must  be  differentiated  from  vascular  diseases  of  the  cerebral 
axis:  in  this  last  condition  the  onset  is  generally  much  more 
sudden,  and  there  are  present  symptoms  of  vascular  disease, 
evidence  that  the  lesion  is  not  limited  to  the  nuclei  of  the  motor 
cranial  nerves,  and  the  condition  is  usually  not  bilateral  without 
the  existence  of  symptoms  pointing  to  extensive  involvement  of 
the  cerebral  axis.  It  is  differentiated  from  tumors  situated  in 
the  neighborhood  by  the  fact  that  in  the  latter  there  are  usually 
some  of  the  general  symptoms  of  Id  rain  tumor ;  the  development 
of  symptoms  is,  as  a  rule,  much  slower,  and  there  is  commonly 
evidence  of  extensive  involvement  of  the  cerebral  axis,  which 
manifests  itself  as  a  spastic  condition  of  the  extremities; 
and  the  symptoms  are  not  symmetrically  bilateral.  From 
multiple  sclerosis  the  disease  is  distinguished  by  the  spinal  and 
cerebral  symptoms.  From  amyotrophic  lateral  sclerosis  it  is 
differentiated  by  the  presence  of  spinal  symptoms.  From 
multiple  neuritis  in  which  the  cranial  nerves  are  involved,  especi- 
ally in  postdiphtheric  paralysis,  it  is  distinguished  by  the  his- 
tory, by  the  comparatively  rapid  onset  and  rapid  progress  of  the 
symptoms,  by  the  distribution  of  the  paralysis,  and  by  the 
occurrence  of  other  symptoms,  such  as  sensory  disturbances  and 
involvement  of  the  extremities.  It  is  to  be  differentiated  from 
pseudobulbar  paralysis,  in  which  condition  bilateral  lesions  in 


PROGRESSIVE   BULBAR  PARALYSIS  277 

the  lower  part  of  the  precentral  convolutions,  or  in  the  motor 
pathways  from  these  centers  to  the  cerebral  axis,  bring  about 
bilateral  paralysis  of  the  tongue  and  face.  This  may  be  due  to 
a  congenital  defect,  multiple  sclerosis,  or  several  apoplectic 
attacks.  In  this  condition  a  differential  diagnosis  is  made  with 
comparative  ease  by  the  absence  of  atrophy  and  of  fibrillary 
tremors;  the  history  of  the  onset;  the  presence  of  symptoms 
pointing  to  some  vascular  or  other  disease,  and  the  usual  pres- 
ence of  aphasia.  From  myasthenia  gravis  it  is  differentiated 
by  the  fact  that  in  the  latter  condition  there  is  more  or  less 
general  muscular  fatigue,  which  appears  rapidly  upon  exertion; 
the  frequency  with  which  the  ocular  muscles  are  affected;  the 
absence  of  fibrillary  tremors;  the  presence  of  the  myasthenic 
reaction,  and  the  frequency  of  intermissions  when  the  patient 
seems  to  be  almost  entirely  well. 

Treatment. — The  most  important  factor  in  the  treatment  of 
this  conditon  is  the  maintenance  of  nutrition  of  the  patient. 
This  is  best  accomplished  by  giving  nutritious  food  in  as  small  a 
bulk  as  possible,  to  be  followed  later  by  semisolid  food.  If 
necessar}',  a  feeding-tube  should  be  used.  The  patient's  general 
health  is  to  be  maintained  by  an  abundance  of  fresh  air,  general 
massage,  hot  and  cold  sponge-baths,  etc.  Str}"chnin  in  proper 
doses,  in  conjunction  or  alternating  with  tonics,  the  combination 
of  iron,  quinin,  and  strychnin,  etc.,  are  indicated.  Water  should 
be  given  freely.  Great  care  should  be  exercised  in  feeding  the 
patient  so  as  to  prevent  food  or  liquids  entering  the  respiratory 
passages. 


DISEASES   OF  THE  SPINAL  CORD 

Owing  to  the  anatomic  construction  and  physiologic  functions 
of  the  various  portions  of  the  spinal  cord,  this  structure  may  be 
affected  pathologically  in  several  ways.  Disease  processes  may 
be  limited  more  or  less  exclusively  to  the  gray  matter;  they  may 
be  confined  to  the  tracts,  or  they  may  be  more  or  less  diffuse, 
involving  both  the  gray  and  the  white  matter. 

ACUTE  ANTERIOR  POLIOMYELITIS 

This  condition,  also  known  as  infantile  spinal  paralysis  or 
atrophic  spinal  paralysis,  is  an  acute  infectious  disease  seen 
chiefly  among  children,  but  also  affecting  adults.  It  occurs  in 
epidemics  or  sporadically. 

Etiology. — This  disease  is  seen  most  frequently  in  the  first 
five  years  of  life.  It  is  more  common  during  the  later  summer 
months  than  at  any  other  period  of  the  year.  Exposure,  over- 
exertion, and  trauma  may  predispose  to  the  condition.  It  may 
also  occur  in  connection  with  various  infectious  diseases,  such 
as  measles,  scarlet  fever,  pneumonia,  etc.  The  specific  cause  of 
the  disease  is  a  microorganism  that  probably  enters  the  system 
through  the  nasal  mucous  membrane. 

Flexner  has  shown  that  the  secretion  from  the  mucous  mem- 
brane of  the  nose  and  mouth  contains  the  infective  organism. 
The  period  of  incubation  is  from  a  few  days  to  two  weeks.  The 
disease  may  be  carried  by  persons  not  affected.  Epidemics 
of  the  disease  have  frequently  occurred,  and  it  has  usually  been 
possible  to  trace  the  transmission  of  the  affection  from  person 
to  person  or  from  place  to  place. 

Pathology. — Examination  of  the  spinal  cord  of  a  person  dying 
during  the  acute  stage  of  the  attack  shows  an  active  congestion 
and  inflammation  of  the  meninges  and  of  the  white  and  gray 
278 


ACUTE   ANTERIOR   POLIOMYELITIS  279 

matter  of  the  spinal  cord,  and  sometimes  of  the  brain.  The 
congestion  is  more  marked  in  the  anterior  part  of  the  gray  matter, 
on  account  of  its  greater  blood  supply.  In  some  cases  the  pons, 
medulla,  and  crura  cerebri  are  also  involved  along  with  the 
spinal  cord.  The  degree  of  inflammation  in  the  meninges 
varies  with  the  severity  of  the  disease.  It  is  probable  that  in 
cases  of  the  abortive  type  there  is  merely  a  congestion  in  the 
distribution  of  the  anterior  spinal  artery,  which  rapidly  dis- 
appears and  leaves  no  permanent  symptoms.  As  the  result  of 
congestion  and  inflammation  of  the  spinal  cord  and  meninges 
these  structures  are  the  seat  of  numerous  small  hemorrhages, 
infiltration,  and  emxigration  of  leukocytes.  The  leukocytes  and 
many  small  round  cells  infiltrate  the  tissues.  In  the  more 
severe  cases  the  nerve-cells  undergo  degeneration  and  are  ab- 
sorbed. In  some  cases  degeneration  does  not  go  on  to  complete 
destruction  and  recovery  is  possible.  The  neurogliar  elements 
also  undergo  destructive  changes  varying  in  extent  with  the 
severity  of  the  lesion.  As  the  result  of  atrophy  and  sclerosis 
there  is  a  decrease  in  the  size  of  the  anterior  horn.  When  the 
gray  matter  which  lies  close  to  the  central  canal  in  involved, 
there  is,  in  addition  to  the  paralysis,  marked  disturbance  in  the 
growth  of  the  limbs,  this  portion  of  the  gray  matter  apparently 
bearing  a  close  relation  to  the  growth  of  the  tissue.  Early  in 
the  disease,  before  the  development  of  the  paralysis,  the  spinal 
fluid  contains  lymphocytes,  both  large  and  small,  and  poly- 
nuclear  leukocytes,  and  it  is  more  or  less  cloudy  in  appearance. 
As  the  paralysis  develops  this  condition  disappears. 

Symptoms. — ^The  disease  usually  begins  acutely,  the  tem- 
perature ranging  from  99°  to  104°  F.  Along  with  the  fever 
there  are  general  constitutional  disturbances,  such  as  loss  of 
appetite,  vomiting,  intestinal  disorders,  stupor,  delirium,  and 
sometimes  convulsions.  In  some  cases  these  symptoms  are 
accompanied  by  stiffness  and  pain  in  the  back,  headache,  etc., 
closely  resembling  meningitis.  During  this  stage,  which  may 
last  from  a  few  hours  to  several  days,  there  is  considerable 
prostration  and  often  more  or  less  pain  and  tenderness  of  the 
extremities.  At  this  time  it  is  usually  impossible  to  determine 
the  nature  of  the  illness.     Toward  the  close  of  this  stage  the 


28o  MANUAL   OF   NERVOUS   DISEASES 

paralysis  or  weakness,  which  is  wide-spread,  is  first  noticed. 
If  the  fever  is  mild,  it  may  be  overlooked,  the  paralysis  being 
the  first  symptom  noticed.  The  paralysis  may  at  first  involve 
all  four  extremities,  but  more  commonly  it  affects  one  extremity, 
either  an  arm  or  a  leg,  or  both  arms,  or  both  legs  and  one  arm, 
etc.  In  some  cases  the  face  or  ocular  muscles  may  be  involved, 
but  this  is  rare.  Not  infrequently,  in  addition  to  the  involve- 
ment of  the  extremities,  the  trunk  muscles  may  be  affected 
(Figs.  117,  118,  119). 

At  the  onset  the  paralysis  is  usually  more  extensive  in  dis- 
tribution than  it  is  destined  permanently  to  be.  It  is  always 
flaccid  in  type,  and  as  time  passes  marked  atrophy  of  the  affected 
muscles  takes  place.  The  electric  reaction  depends  upon  the 
extent  and  the  severity  of  the  involvement.  Within  a  short 
time  after  the  attack  has  passed  off  there  is  a  return  of  power 
in  the  muscles  that  were  least  affected,  and  they  contract  to  vol- 
untary impulses,  and  although  the  paralysis  may  have  been  very 
extensive  at  the  onset,  it  may  finally  be  limited  to  a  very  few 
muscles.  Frequently  the  paralysis  may  involve  only  parts  of 
several  muscles. 

The  tendon-reflexes  associated  with  the  affected  muscles  are 
either  lost  or  markedly  decreased.  Pain  is  not  a  permanent 
symptom,  but  in  a  few  cases  it  is  so  severe  that  the  condition 
may  be  mistaken  for  rheumatism.  Sensibility  is  not  diminished ; 
skin  reflexes  are  not  disturbed,  except  in  so  far  as  they  are  inter- 
fered with  by  the  presence  of  the  paralysis. 

The  Electric  Reaction. — In  those  muscles  that  are  least 
affected  there  is  usually  a  response  to  both  faradic  and  galvanic 
current.  In  those  muscles  that  are  more  severly  affected,  there 
is  complete  reaction  of  degeneration,  and  if  the  muscle  continues 
to  atrophy  and  the  muscle  tissue  to  disappear,  there  finally 
occurs  complete  loss  of  all  electric  contractility. 

Vasomotor  Trophic  Symptoms. — In  many  cases  the  circulation 
in  the  affected  limb  is  impaired  and  the  limb  feels  cold  and  pre- 
sents a  bluish  appearance.  When  the  affection  has  been  at  all 
severe,  and  in  fact  in  practically  all  cases,  there  is  some  arrest 
of  growth  as  well  as  deformity.  The  affected  limb  is  tardy  in 
development,  and  this  defect  involves  both  the  soft  and  the  bony 


ACUTE   ANTERIOR  POLIOMYELITIS 


281 


structures   of   the   limb.     Bowel   and   bladder   control    is   not 
affected.     The  deformity  arises  in  consequence   of    the    con- 


Fig.  117. — Anterior  poliomyelitis. 
In  the  acute  stage  in  this  case  there 
was  complete  paralysis  of  the  mus- 
cles of  the  trunk,  neck,  upper  and 
lower  extremities.  At  the  present 
time  there  remains  weakness  of  the 
neck  muscles  and  of  the  muscles 
which  fix  the  scapulae  to  the  chest 
walls. 


Fig.  118. — Anterior  poHomyelitis, 
shoulder  type  right  side,  leg  t3^pe 
left  side. 


tracture  of  the  antagonists  to  the  paralyzed  muscles,  the  con- 
traction gradually  resulting  in  shortening.  Flail-joints  result 
when  the  muscles  that  support  the  structures  at  a  joint  are 


282  MANUAL   OF   NERVOUS   DISEASES 

the  seat  of  paralysis,  and  occur  more  often  at  the  hip  and  shoul- 
der. The  distribution  of  the  paralysis  varies  greatly  in  dif- 
ferent cases.    When  the  paralysis  affects  the  lower  extremity,  two 


Fig.  119. — Anterior  poliomyelitis. 

types  of  disease  may  be  recognized:  the  leg  type — the  paralysis 
involving  some  or  all  of  the  muscles  on  the  anterior  or  anterior 
and  posterior  aspect  of  the  leg,  bringing  about  interference  with 


ACUTE    ANTERIOR   POLIOMYELITIS  283 

the  movements  of  the  foot.  In  some  cases  there  is  foot-drop, 
with  ability  to  move  the  toes.  If  the  paralysis  is  persistent, 
deformity  eventually  occurs.  In  the  thigh  type  the  muscles 
about  the  hip-joint  are  chiefly  affected,  those  on  the  inner  part 
of  the  thigh  and  below  the  knee  often  escaping.  It  is  in  these 
cases  that  we  have  the  flail-joint  at  the  hip.  In  some  cases  all 
the  muscles  of  the  lower  extremities  may  be  involved. 

Two  t}-pes  of  aft'ection  are  also  observed  when  the  arm  is  in- 
volved: in  the  lower  arm  type  the  muscles  below  the  elbow  are 
involved,  whereas  in  other  cases  the  muscles  of  the  hand  are 
affected;  in  the  upper  arm  type  the  muscles  about  the  shoulder 
and  arm  are  involved.  In  many  cases  along  with  the  involve- 
ment of  the  extremities  there  is  also  affection  of  the  muscles  of 
the  trunk — rarely,  of  the  muscles  of  the  trunk  alone. 

The  paralysis  is  rarely  s}Tnmetric  (Fig.  118).  The  chief  char- 
acteristics of  this  form  of  paralysis  is  that  it  is  atrophic;  that  dis- 
tribution of  the  paralysis  bears  no  relation  to  the  arrangement  of 
the  muscles  in  the  limb,  to  the  action  of  the  muscles  in  producing 
movement,  or  to  the  nerve-supply,  but  is  wholh'  dependent  upon 
the  arrangement  of  groups  of  cells  in  the  anterior  horns  of  the 
spinal  cord  which  control  muscles  or  parts  of  muscles. 

Diagnosis. — This  condition  must  be  differentiated  horn,  febrile 
states,  accompanied  by  immobility  of  one  or  more  of  the  ex- 
tremities, from  rheumatism,  rickets,  osteomyelitis,  fractures, 
etc.  In  these  aff'ections  a  proper  examination  will  always  dis- 
close the  fact  that  pain  is  the  cause  of  the  immobility  of  the  limb, 
and  that  when  an  effort  is  made  to  move  the  part,  muscular 
contraction  can  be  observ^ed.  In  addition  to  this  the  electric 
reaction  and  the  presence  of  the  deep  reflexes  will  make  the 
diagnosis  clear. 

From  multiple  neuritis  the  condition  is  differentiated  by  the 
facts  that  multiple  neuritis  occurs  very  rarely  in  childhood;  does 
not  attain  full  development  so  quickly;  the  feverish  stage  is  apt 
to  last  longer;  pain  is  more  marked,  the  nerves  and  muscles 
being  tender  to  pressure;  disturbance  of  sensibility  is  usually 
present;  the  distribution  of  the  paralysis  is  confined  to  muscles 
supplied  by  the  peripheral  nerves. 

From  infantile  cerebral  paralysis  this  condition  is  differentiated 


284  MANUAL  OF  NERVOUS  DISEASES 

by  the  distribution  of  the  paralysis,  which  is  more  apt  to  be 
hemiplegic  or  diplegic  in  type;  the  paralysis  is  spastic,  and  the 
reflexes  are  increased.  From  birth  palsy  or  a  localized  injury  of 
the  brachial  plexus  the  disease  is  differentiated  by  the  history 
of  the  case.  Hemorrhage  into  the  spinal  cord  in  children  is  ex- 
tremely rare;  if  the  hemorrhage  is  limited  to  the  gray  matter, 
the  symptoms  will  resemble  those  of  the  anterior  poliomyelitis, 
except  for  the  very  acute  onset  and  the  absence  of  fever.  In 
myelitis  the  involvement  of  the  spinal  cord  is  usually  diffuse, 
and  in  addition  to  the  symptoms  of  involvement  of  the  gray 
matter  there  is  disturbance  of  sensibility,  of  motion,  and  of 
control  of  the  bowels  and  bladder,  due  to  interference  with  the 
transmission  of  the  impulses  up  and  down  the  cord.  If  we  have 
reason  to  suspect  the  existence  of  poliomyelitis,  examination  of 
the  spinal  fluid,  made  on  the  second  or  third  day  of  the  febrile 
condition,  before  the  paralysis  has  appeared,  makes  a  diagnosis 
possible.  Cerebrospinal  fluid  is  increased  in  amount,  is  opa- 
lescent, and  contains  a  large  number  of  small  and  large  lym- 
phocytes and  a  few  polymorphonuclear  leukocytes,  and  the 
fluid  gives  a  protein  reaction  to  the  butyric-acid  test. 

Prognosis. — ^The  prognosis  is  favorable  as  regards  life.  In  those 
cases  that  point  toward  involvement  of  the  upper  cervical  region 
or  brain-stem,  however,  the  prognosis  as  to  life  is  very  grave.  The 
prognosis  as  to  complete  recovery  is  most  unfavorable.  In  some 
epidemics  many  cases  occur  in  which  recovery  is  complete.  In 
the  majority  of  cases  marked  improvement  may  be  looked  for. 
The  more  circumscribed  the  paralysis  at  the  onset  of  the  attack, 
the  less  permanent  will  the  disturbance  of  function  be.  As  a 
rule,  a  limb  that  is  affected  never  entirely  regains  its  power,  and 
usually  shows  atrophy  and  shortening.  The  electric  examination 
is  of  assistance  in  making  a  prognosis:  muscles  that  respond  to 
the  faradic  current  after  three  wrecks  usually  recover  completely; 
those  that  fail  to  react  to  this  current  may  improve,  but  will  not 
recover  completely.  Improvement  extends  over  a  period  of 
from  six  months  to  two  years.  The  prognosis  as  to  recovery  of 
function  is  somewhat  affected  by  secondary  changes,  such  as 
contractures  and  interference  with  growth. 

Treatment. — During  the  initial  or  febrile  stage  the  patient 


ACUTE    ANTERIOR   POLIOMYELITIS  285 

should  be  kept  absolutely  quiet  in  bed,  and  active  movements 
prevented  as  far  as  possible.  IMild  counterirritation  may  be 
made  along  the  spine,  and  the  application  of  dry  cups  or  leeches 
to  the  back.  The  gastro-intestinal  tract  should  be  cleared  with 
a  mild  purgative,  and  diaphoresis  induced  by  warm  drinks  and 
hot  applications.  If  the  temperature  is  high,  sponging  with 
alcohol  is  advisable.  If  the  child  is  in  great  pain  or  there  is 
marked  restlessness,  the  bromids,  with  or  without  codein,  may 
be  given.  The  diet  should  be  light,  and  the  patient  should  be 
persuaded  to  drink  as  much  w^ater  as  possible.  Owing  to  the 
fact  that  this  is  a  contagious  disease,  the  child  should  be  com- 
pletely isolated,  and  the  nose  and  throat  sprayed  with  a  mild 
antiseptic  solution  every  few  hours;  this  should  be  continued 
for  several  weeks  after  the  fever  has  subsided. 

During  the  acute  stage  sodium  salicylate  in  appropriate 
dose  may  be  given.  Usually  the  constitutional  symptoms 
disappear  at  the  end  of  a  w^eek  or  ten  days,  and  the 
paralysis,  which  was  very  extensive  at  first,  shows  evidence  of 
improvement  and  becomes  limited  to  a  smaller  area.  At  this 
stage  it  is  advisable  to  give  strychnin  in  proper  doses,  and  to 
encourage  the  child  to  use  those  portions  of  the  body  that  can 
be  moved;  this  last  can  sometimes  be  accomplished  by  placing 
the  child  in  a  tub  of  w^arm  water  and  encouraging  it  to  play. 
These  w^arm  baths  must,  of  course,  be  given  under  proper  super- 
vision, and  the  patient  must  not  be  permitted  to  remain  in  the 
water  longer  than  fifteen  minutes.     They  may  be  given  daily. 

Deformities  are  to  be  prevented  as  far  as  possible  by  support- 
ing the  limbs  and  dependent  portions  of  the  body,  and  by  mas- 
sage and  passive  exercise.  Small  doses  of  potassium  iodid  or 
syrup  of  iodid  of  iron  seem  to  be  of  benefit.  Skilful  massage, 
gymnastic  exercise  under  proper  super\dsion,  and  the  use  of 
electricity  will  frequently  assist  in  the  recovery  of  muscles  that 
would  otherwise  not  regain  their  functions.  This  treatment 
should  be  persisted  in  for  from  one  to  two  years.  The  general 
health  and  physical  condition  of  the  patient  should  be  carefully 
looked  after.  Surgical  measures  and  the  various  forms  of 
orthopedic  apparatus  may  restore,  at  least  partially,  the  functions 
of  parts  of  the  body  that  do  not  respond  to  medical  treatment. 


286  MANUAL   OF   NERVOUS   DISEASES 

SUBACUTE  AND  CHRONIC  ANTERIOR  POLIOMY- 
ELITIS (PROGRESSIVE  SPINAL  MUSCULAR 
ATROPHY) 

This  is  a  rare  form  of  spinal  cord  disease  in  which  there  is  a 
progressive  development  of  paralysis  due  to  a  slowly  advancing 
atrophy  of  the  primary  motor  neurons  of  the  cord. 

Etiology. — The  disease  generally  affects  adults.  Trauma, 
toxic  substances,  and  disturbance  of  the  lymphatic  circulation 
are  believed  to  be  among  the  causative  agents. 

Pathology. — Examination  of  the  spinal  cord  of  an  individual 
who  has  suffered  from  this  disease  shows  an  atrophy  of  the  an- 
terior roots  and  a  shrinkage  of  the  anterior  horn  cells  in  different 
regions  of  the  cord.  The  changes  in  the  cells  vary  from  a  simple 
decrease  in  size  of  the  cell  and  its  nucleus  to  an  almost  complete 
disappearance.  In  addition  to  the  atrophy  of  the  cells,  there  are 
also  atrophy  and  finally  disappearance  of  the  dendrites  and 
axons.  As  a  consequence  of  this  degeneration  there  is  atrophy 
of  the  anterior  root-fibers  and  of  the  nerves  to  their  termination 
in  the  muscles.  The  affected  muscles  also  undergo  changes  in 
which  there  is  a  simple  atrophy  of  the  muscle-fibers. 

Owing  to  the  fact  that  the  lesion  may  begin  in  different  parts 
of  the  spinal  cord,  three  clinical  types  of  this  disease  are  en- 
countered. In  the  first  type,  atrophy  begins  in  the  cells  in  the 
lower  portions  of  the  spinal  cord,  gradually  extending  upward, 
but  not  involving  the  arms.  In  the  second  type,  known  as 
Duchenne's  subacute  ascending  paralysis,  the  atrophy  begins 
in  the  cells  in  the  lower  part  of  the  cord,  and  gradually  advances 
upward  until  all  the  motor  cells  are  involved.  In  the  third  type, 
the  Aran-Duchenne  type  of  progressive  atrophy,  the  atrophic 
process  begins  in  groups  of  cells  in  the  lower  part  of  the  cervical 
or  the  upper  dorsal  region  of  the  cord,  and  as  the  disease  ad- 
vances the  upper  cervical  segments  become  affected,  and  later 
the  lumbar  region  is  involved. 

Symptoms. — The  symptoms  of  these  three  types  of  this  dis- 
ease vary  only  in  that  different  regions  of  the  cord  are  primarily 
affected.  In  chronic  ascending  paralysis  there  is  a  slowly 
advancing  flaccid  paralysis,  beginning  in  the  muscles  that  flex 


SUBACUTE   AND    CHRONIC    ANTERIOR   POLIOMYELITIS      287 

the  foot  and  extend  the  toes,  first  one  leg,  and  then,  within  a 
few  months  the  other  leg,  being  affected.  The  paralysis  and 
atrophy  gradually  become  more  evident  until  finally  a  fully 
developed  foot-drop  appears.  Along  with  the  paralysis  and 
atrophy  there  is  usually  a  fine  fibrillary  tremor  in  the  affected 
muscles.  As  the  disease  progresses  the  adductors  of  the  thigh 
and  the  glutei  muscles  become  affected,  and  difficulty  in  going 
up  steps  and  in  rising  to  the  erect  position  after  sitting  ensues. 
At  about  the  same  time  that  these  muscles  are  involved  the 
muscles  of  the  posterior  aspect  of  the  leg  and  thigh  also  become 
affected.  The  extent  of  paralysis  corresponds  to  the  degree  of 
atrophy  present.  There  are  no  sensory  disturbances,  and  no 
interference  with  bowel  anS^tadder  tunctions.  The  reflexes 
and  the  electric  reactions  in  the  affected  muscles  depend  upon 
the^  amount  of  muscle  tissue  that  is  unaft'ected.  In  the  first 
type  of  cases  the  disease  may  not  advance  be}^ond  the  involve- 
ment of  the  legs  and  thighs,  the  patient  living  for  years  in  a  state 
of  paraplegia. 

In  the  second  type  of  cases  the  disease  begins  in  the  same  way 
as  in  the  first  type,  progresses  upward,  the  muscles  of  the  back, 
trunk,  and  finally  of  the  shoulder  and  hands  becoming  involved. 
If  the  patient  does  not  die  of  some  intercurrent  condition,  the 
motor  cranial  nuclei  become  involved. 

In  the  Aran-Duchenne  t\^e  the  muscles  that  move  the  thumb 
are  the  first  to  become  aff'ected.  As  the  condition  advances  the 
small  muscles  that  move  the  fingers  become  involved,  making 
the  finer  movements  of  the  fi^ngers  clumsy  of  impossible.  As 
the  atrophy  progresses  there  is  a  flattening  of  the  thenar  and 
h^'pothenar  eminences,  and  hollows  are  produced  between  the 
metacarpal  bones.  Owing  to  paralysis  of  the  uiterossei  the 
first  phalanges  of  the  fingers  cannot  be  flexed,  and  as  there  is  no 
opposition  to  the  long  flexors  and  extensors  of  the  fingers,  the 
hand  assumes  a  characteristic  position  in  which  it  resembles  a 
a  claw.  As  a  rule,  one  hand  is  involved  before  the  other.  There 
is  a  tendency  to  gradual  extension  of  the  paralysis  and  atrophy 
to  the  shoulder  and  then  to  the  muscles  of  the  arm,  until  the 
entire  arm  and  forearm  are  completely  paralyzed.  The  disease 
may  then  involve  the  muscles  of  the  neck  and  of  the  trunk,  and 


288  MANUAL   OF   NERVOUS  DISEASES 

if  the  patient  does  not  die  from  some  intercurrent  affection  the 
legs  finally  become  involved. 

The  characteristic  symptoms  of  this  disease  are  paralysis  and 
atrophy,  the  extent  of  the  paralysis  depending  upon  the  amount 
of  atrophy  present;  fibrillary  tremors  occurring  in  the  paralyzed 
muscles;  disturbance  of  the  electric  reaction,  depending  upon 
the  amount  of  muscle  tissue  that  remains  intact:  at  first  there 
is  partial  reaction  of  degeneration,  later  complete  reaction  of 
degeneration,  and  finally  loss  of  electric  response  occurs.  The 
deep  reflex  reaction  also  depends  upon  the  amount  of  muscle^ 
tissue  remaining  intact,  there  being  a  gradual  diminution  of  the 
reflex  response  as  the  muscle  atrophies. 

Course  and  Prognosis. — The  duration  of  the  disease  varies 
from  two  to  many  years.  Spontaneous  arrest  of  atrophy  may 
occur  at  any  time  during  the  course  of  the  affection,  but  the 
prognosis  is  serious,  as  there  is  a  tendency  for  the  disease  to  go  on 
to  extreme  atrophy,  death  ensuing  as  the  result  of  respiratory 
involvement  or  bulbar  paralysis.  The  three  types  described 
show  the  usual  form  of  progress  of  the  disease,  but  cases  occur 
that  do  not  conform  to  these  types  in  this  respect. 

Diagnosis. — This  disease  must  be  differentiated  from  amyo- 
trophic lateral  sclerosis,  muscular  dystrophy,  syringomyelia, 
and  multiple  neuritis. 

In  amyotrophic  lateral  sclerosis  the  increase  of  the  knee  reflexes 
appears  early,  with  the  development  of  the  Babinski  reflex;  the 
paralysis  is  of  the  spastic  type ;  the  progress  of  the  case  is  usually 
more  rapid,  and  the  bulbar  symptoms  either  precede  the  affection 
of  the  limb  or  occur  early  in  the  disease.  In  this  affection  there 
is  a  combination  of  the  symptoms  of  a  progressive  muscular 
atrophy  and  of  lateral  sclerosis. 

In  muscular  dystrophy  there  is  an  absence  of  fibrillary  tremors, 
and  the  appearance,  frequently,  of  a  hypertrophy  or  pseudo- 
hypertrophy.    The  disease  also  develops  usually  in  childhood. 

In  syringomyelia  there  are  early  appearance  of  sensory  dis- 
turbances of  a  characteristic  nature, — a  loss  of  sensibility  of 
pain,  temperature,  with  retention  of  tactile  sensibility;  the  onset 
of  trophic  symptoms,  and,  usually,  increase  of  the  knee  reflexes. 

In  multiple  neuritis  the  presence  of  sensory  disturbances,  the 


AMYOTROPHIC    LATEILVL    SCLEROSIS  289 

loss  of  deep  reflexes,  and  the  absence  of  fibrillary  tremors  and 
presence  of  superficial  vasomotor  and  trophic  disturbances  will 
serve  to  differentiate  the  condition. 

Treatment. — The  treatment  of  this  affection  resolves  itself 
into  looking  after  the  general  health  of  the  patient.  He  is  to  be 
given  wholesome  food,  to  maintain  the  general  nutrition,  fresh 
air,  and  a  very  moderate  amount  of  exercise.  Fatigue  of  the 
affected  muscles  is  to  be  absolutely  avoided,  and  infections  of 
all  kinds  guarded  against.  General  massage  and  passive 
exercise  are  of  value  in  so  far  as  they  promote  the  circulation, 
thereby  increasing  the  nourishment  of  the  muscles.  Str^xhnin 
in  proper  doses  is  to  be  given  three  or  four  times  a  day,  and 
arsenic  and  other  general  tonics  will  be  found  beneficial. 

Deformity  should  be  prevented,  and  suitable  apparatus  may 
be  worn  to  assist  the  patient  in  his  activities. 

AMYOTROPHIC   LATERAL   SCLEROSIS    (CHARCOT'S 

DISEASE) 

This  disease  usually  develops  in  adult  life.  Very  little  is 
known  as  to  its  cause,  some  assuming  that  there  is  a  congenital 
predisposition  to  weakness  of  the  motor  elements  of  the  nervous 
system. 

Pathology. — The  spinal  cord  shows  degeneration  and  atrophy 
of  the  pyramidal  tracts  and  of  the  anterior  horns,  but  no  in- 
volvement of  the  sensory  pathways.  In  the  anterior  horns 
there  is  a  marked  degeneration  of  the  large  motor  nerve  cells  and 
their  processes.  In  most  cases  it  is  the  cerv^ical  enlargement  that 
is  principally  involved.  In  the  medulla  and  pons  there  is  an 
atrophy  of  the  pyramidal  tracts  and  of  the  m.otor  nuclei  of  the 
twelfth,  the  seventh,  and  frequently  the  tenth,  eleventh,  and 
fifth  ner\xs.  In  some  cases  the  atrophy  of  the  p3Tamidal  tracts 
can  be  traced  as  high  as  the  precentral  convolution. 

Symptoms. — This  disease  is  characterized  by  three  sets  of 
symptoms — those  of  chronic  anterior  poliomyelitis,  of  lateral 
sclerosis,  and  of  bulbar  paralysis.  The  onset  is  usually  marked 
by  weakness  and  atrophy  in  the  upper  extremities,  or  weakness 
and  stiffness  in  the  lower  extremities.  As  a  rule,  one  arm  or 
19 


290 


MANUAL   or   NERVOUS   DISEASES 


one  leg  is  more  markedly  affected  than  the  other.  The  paral- 
ysis and  atrophy  gradually  extend  and  become  more  severe, 
and  at  the  same  time  muscular  rigidity  increases.  The  disease 
is  slowly  progressive,  and  within  a  year  both  arms  and  legs  may 

be  in  a  state  of  advanced  paralysis. 
Fibrillary  twitchings  are  usually 
present,  and  may  precede  the  paral- 
ysis. There  is  a  complete  absence 
of  sensory  symptoms.  The  tendon 
reflexes  are  markedly  increased,  and 
motor  weakness  is  generally  com- 
bined with  atrophy  and  contrac- 
tures. The  disease  usually  begins 
with  fibrillary  twitchings,  which  may 
be  more  or  less  diffuse.  These  may 
be  followed  either  by  stiffness  in  the 
legs  or  by  weakness  in  the  upper 
extremities,  the  weakness  affecting 
the  smaller  muscles  of  the  hand. 
The  weakness  is  followed  by  atrophy, 
producing  a  deformity  that  resem- 
bles ''claw  hand."  Contractures 
develop,  and  the  arms  are.  strongly 
adducted,  with  the  forearm  flexed 
and  the  hand  pronated  (Fig.  1 20) . 

In  the  lower  extremities  there  is 
usuaUy  an  absence  of  atrophy,  but  a 
marked  rigidity  appears  early.  The 
Bahinski  sign  may  or  may  not  be 
present.  The  gait  is  slow  and  of 
the  spastic  type.  In  the  later 
stages  of  the  disease  the  atrophy  also 
affects  the  legs.  In  some  few  cases 
the  disease  begins  with  atrophy  in 
the  lower  extremities,  the  condition  gradually  extending  upward. 
There  are  no  bowel  or  bladder  disturbances.  Later  on  in  the 
disease  the  symptoms  of  bulbar  paralysis  develop.  In  some 
cases  bulbar  paralysis  is  the  first  symptom  to  manifest  itself, 


Fig.  120. — Amyotrophic 
lateral  sclerosis,  showing 
atrophy  of  the  small  muscles 
of  the  hand,  spastic  condi- 
tion of  the  lower  extremities. 


AMYOTROPHIC    LATERAL    SCLEROSIS  291 

the  rigidity  in  the  lower  extremities  and  the  involvement  of  the 
upper  extremities  appearing  later  and  clearing  up  the  diagnosis. 
When  the  bulbar  paralysis  occurs,  it  manifests  itself  first  in 
disturbance  of  speech,  the  patient  at  first  speaking  indistinctly, 
this  giving  place  finally  to  an  anarthria.  At  about  the  same 
time,  or  shortly  thereafter,  difficulty  in  swallowing  and  in  the 
mastication  of  food  is  noticed.  This  form  of  bulbar  paralysis 
may  be  preceded  by  rigidity  of  the  facial  muscles  and  by  an 
increase  of  the  jaw- jerk.  As  the  disease  advances  the  face  be- 
comes expressionless,  the  lower  jaw  drops,  and  saliva  trickles 
out  between  the  lips.  Speech  now  becomes  unintelligible,  and 
swallowing  is  no  longer  possible.  Usually  the  patient  becomes 
emotional,  laughing  and  w^eeping  readily. 

Differential  Diagnosis. — It  is  distinguished  from  chronic 
anterior  poliomyelitis  by  the  presence  of  spastic  s}Tnptoms, 
along  wdth  the  atrophic  paralysis,  and  in  typical  cases  the  dis- 
tribution of  the  symptoms.  From  multiple  sclerosis  it  is  differ- 
entiated by  the  absence  of  nystagmus,  atrophy  of  the  optic 
nerve,  peculiar  speech  disturbance,  intention  tremors,  etc. 
From  compression  of  the  spinal  cord  in  the  cervical  region  the 
differentiation  is  made  by  the  absence  of  sensory  disturbances 
and  of  bowel  and  bladder  disorders. 

Course  and  Prognosis. — ^The  course  of  this  disease  is  usually 
progressive,  lasting  from  two  to  four  years,  although  some  cases 
may  be  of  longer  duration.  The  prognosis  as  to  life  is  absolutely 
hopeless. 

Treatment. — This  is  limited  to  making  the  patient  as  com- 
fortable as  possible.  Where  there  is  difficulty  in  swallowing, 
feeding  by  tube  will  be  necessar}^  in  order  to  maintain  the 
general  nutrition.  The  stiffness  may  be  relieved  by  massage, 
passive  movement,  and  prolonged  warm  baths.  Sedatives  are 
indicated  to  relieve  the  muscle  rigidity  and  frequently  to  quiet 
the  patient. 


292  MANUAL   OF   NERVOUS   DISEASES 

SYRINGOMYELIA   AND    SPINAL   GLIOSIS 

Syringomyelia  is  a  condition  characterized  by  the  formation 
of  a  cavity  within  the  spinal  cord;  spinal  gliosis  is  a  condition 
in  which  a  new-growth  takes  place  in  the  substance  of  the  spinal 
cord,  without  leading  to  a  material  increase  in  the  size  of  this 
organ.  Cavities  of  the  cord  are  frequently  produced  by  dis- 
integration in  this  form  of  new-growth.  For  present  purposes 
both  conditions  may  be  considered  together. 

Etiology. — Cavity  formation  has  been  ascribed  to  congenital 
dilatation  of  the  central  canal,  secondary  to  a  central  myelitis, 
disintegration  of  tumors,  or  a  gradual  enlargement  of  a  con- 
genital cavity  in  the  cord.  Glial  tumors  have  been  shown  to  be 
the  result  of  nests  of  glia-cells  left  behind  in  the  developmental 
period  in  the  neighborhood  of  the  central  canal  or  in  the  region 
of  the  posterior  septum.  These  nests  tend,  either  spontaneously 
or  under  the  influence  of  trauma,  to  proliferate,  and  by  their 
increase  to  form  longitudinal  tumors. 

Pathology. — The  spinal  meninges  are  usually  normal.  The 
cord  either  appears  unaltered  or  slightly  larger  or  irregular  in 
outline.  On  section  of  the  cord  a  cavity  of  varying  size  is  seen. 
In  other  cases  section  of  the  cord  reveals  the  presence  of  a  tumor 
of  varying  size  and  shape,  occupying  the  center  of  the  cord,  and 
involving  to  a  certain  extent  the  gray  matter.  The  tumor  or 
cavity  usually  extends  longitudinally,  and  varies  as  to  the  extent 
of  its  longitudinal  growth  and  the  amount  of  gray  matter  that 
is  involved.  Microscopic  examination  of  the  tumor  shows  that 
it  consists  of  glia-cells  and  fibers.  The  cavities  are  usually  lined 
by  a  firm,  compact  membrane  in  which  a  layer  of  endothelium 
can  sometimes  be  recognized. 

Symptoms. — The  condition  is  characterized  by  the  presence  of 
three  characteristic  groups  of  symptoms,  which  are  present  in 
the  majority  of  cases:  (i)  Disturbance  of  sensation:  there  is 
usually  a  loss  of  sensibility  to  pain  and  thermal  sense,  with  the 
retention  of  tactile  and  muscle  sense ;  this  condition  is  known  as 
dissociation  of  sensation;  patients  so  afilicted  frequently  receive 
injuries  or  burns  without  experiencing  pain,  although  the  sense 
of  touch  is  retained.     The  distribution  of  the  sensory  disturbance 


SYRINGOMYELIA    AND    SPINAL   GLIOSIS  293 

depends  upon  the  location  of  the  lesion  in  the  spinal  cord  and 
upon  its  extent. 

(2)  Trophic  disturbances  occurring  in  the  skin,  muscles,  bones, 
and  joints:  in  many  cases  these  disturbances  are  probably  due 
to  trauma,  which  has  passed  unobserved  because  of  the  loss  of 

•the  sense  of  pain,  and  they  have,  therefore,  been  neglected.  In 
some  cases,  however,  this  is  not  the  case,  and  the  trophic  dis- 
orders are  due  to  disturbance  or  destruction  of  the  trophic 
centers  in  the  spinal  cord.  There  may  be  interference  with  the 
perspiration,  the  part  being  either  abnormally  covered  with 
sweat  or  abnormally  dry.  Superficial  or  indolent  ulcers  may 
form  on  the  skin. 

Morvan  has  described  a  disease  in  which  painless  felons  appear 
upon  the  fingers,  these  being  frequently  associated  wdth  other 
trophic  disturbances  of  the  skin-  and  nails.  This  disease  is 
believed  to  be  a  form  of  syringomyelia. 

Bone  necrosis,  small  abscesses  upon  the  fingers,  ankylosis  of 
the  finger-joints,  abnormal  growth  of  the  nails,  spontaneous 
fractures  due  to  trophic  bone  changes,  affections  of  the  joints 
similar  to  that  type  described  by  Charcot  as  developing  in 
locomotor  ataxia,  etc.,  occur  with  comparative  frequency. 

(3)  Progressive  muscular  atrophy  w^ith  paralysis :  this  muscular 
atrophy  usually  begins  in  the  hands,  and  less  frequently  in  the 
muscles  of  the  shoulder.  As  a  rule,  the  small  muscles  of  the 
hand  are  the  first  to  become  atrophied,  and  the  claw-hand 
position  develops. 

The  atrophic  muscles  generally  show  fibrillary  tremors. 
This  atrophic  paralysis  usually  progresses  very  slowly,  and  one 
side  of  the  body  commonly  shows  greater  involvement  than  the 
other.  Later  on  the  muscles  of  the  trunk,  and  finally  those  of 
the  loW'Cr  extremities,  undergo  atrophy,  and  along  with  this 
paralytic  symptoms  develop.  In  those  cases  in  which  the  lateral 
tracts  are  compressed  spastic  paralysis  with  contractures  and 
deformities  develops.  Unless  the  lumbar  region  is  involved, 
there  is  usually  no  disturbance  of  the  sphincters.  Paresthesias 
are  generally  present,  and  some  patients  complain  of  considerable 
pain.  Among  the  unusual  symptoms  of  this  disease  is  the 
evidence  of  involvement  of  the  cranial  nerves,  this,  of  course. 


294  MANUAL   OF   NERVOUS   DISEASES 

occurring  when  the  brain-stem  becomes  involved  in  the  patho- 
logic process.  The  distribution  of  both  the  motor  and  the  sen- 
sory symptoms  corresponds  to  the  spinal  cord  segments,  and 
not  to  the  distribution  of  the  peripheral  nerves.  The  lower 
cervical  and  upper  dorsal  regions  of  the  cord  are  most  frequently 
affected,  and  as  these  segments  of  the  cord  contain  the  centers 
of  the  cervical  sympathetic,  symptoms  of  paralysis  of  the  sym- 
pathetic of  one  or  of  both  sides  are  usually'present;  these  consist 
of  retraction  of  the  eyeball,  sluggish  pupillary  reaction  with  loss 
of  the  sympathetic  pupil  reflex,  narrowing  of  the  palpebral 
fissure,  and  defective  secretion  of  sweat. 

Diagnosis. — From  progressive  muscular  atrophy  of  spinal 
origin  this  disease  is  distinguished  by  the  presence  of  the  char- 
acteristic sensory  disturbances. 

From  locomotor  ataxia  it  is  distinguished  by  the  absence  of  the 
characteristic  pupillary  and  bowel  and  bladder  dist«irbances,  by 
the  presence  of  dissociation  of  sensation,  muscular  atrophy,  and 
paralysis. 

From  caries  of  the  cervical  spine  it  is  differentiated  by  the 
presence  of  dissociation  of  sensation,  muscular  atrophy,  and 
paralysis. 

Course  and  Prognosis. — The  disease  usually  manifests  itself 
between  the  twenty-fifth  and  the  forty-fifth  year.  Its  progress 
is  generally  very  slow,  and  it  may  extend  over  many  yeaft. 
Remissions  occasionally  occur.  The  prognosis  as  to  complete 
recovery  is  absolutely  unfavorable,  death  usually  occurring  as 
the  result  of  septicemia,  involvement  of  the  medulla,  some 
intercurrent  disease,  cystitis,  bed-sores,  etc. 

Treatment. — No  specific  for  this  disease  is  known.  The 
iodids  may  be  given.  The  general  health  of  the  patient  should 
be  guarded.  Local  conditions,  such  as  ulcerations,  infections, 
etc.,  should  receive  appropriate  attention,  and  the  patient 
should  be  advised  to  avoid  the  risk  of  injury  and  to  exercise 
great  care  in  the  treatment  of  what  to  him  appear  to  be  trivial 
injuries.     Overexertion  should  be  avoided. 


LATERAL    SCLEROSIS  295 

LATERAL   SCLEROSIS 

This  is  a  very  rare  disease,  characterized  by  a  primary  de- 
generation of  the  corticospinal  pathways. 

Etiology. — The  cause  of  this  disease  is  obscure;  overexertion, 
trauma,  infectious  diseases,  etc.,  have  all  been  named  as  causa- 
tive factors.  The  disease  usually  occurs  between  the  twentieth 
and  the  fortieth  year,  and  in  some  cases  more  than  one  member 
of  the  same  family  may  He  affected. 

Pathology. — Examination  of  the  spinal  cord  of  individuals 
who  have  been  affected  with  this  disease  shows  a  degeneration 
which  is  practically  limited  to  the  pyramidal  tracts,  and  which  is 
always  more  marked  in  the  lower  regions  of  the  cord  than  above. 

Symptoms. — At  the  onset  of  the  disease  the  patient  first 
notices  that  he  becomes  fatigued  very  easily,  and  that  there  is  a 
feeling  of  stiffness  in  the  legs.  The  stiffness  and  the  weakness 
gradually  progress  until  a  spastic  paraplegia  develops.  The  deep 
reflexes  are  markedljMiicreased ;  the  add^Ictor  reflexes  are  usually 
present.  The  Babinski  sign,  as  a  rule,  appears  early.  The  muscles 
retain  their  normal  size,  and  there  is  no  qualitative  disturbance 
in  the  electric  reaction.  The  powxr  of  walking  is  usually  retained 
until  late  in  the  disease,  when  the  gait  becomes  gradually  more 
aj;id  more  spastic.  The  muscular  tension  generally  affects  the 
extensors  more  than  the  flexors.  Pain  is  slight  or  absent,  and  is 
due  merely  to  muscular  tension.  There  are  no  sensory  dis- 
turbances, and  the  functions  of  the  bowels  and  bladder  are 
unaffected.  As  the  disease  progresses  the  upper  extremities  also 
become  involved. 

•  Diagnosis. — This  disease  is  very  uncommon.  The  symptoms 
of  a  spastic  paraplegia  are,  in  the  great  majority  of  cases,  merely 
the  early  symptoms  of  some  more  diffuse  disease;  it  is,  therefore, 
highly  important  to  bear  this  fact  in  mind,  and  to  endeavor  to 
discover  the  underlying  condition.  The  disease  must  be  differ- 
entiated from  compression  of  the  cord  as  the  result  of  tumors, 
affections  of  the  meninges  and  of  the  spine,  myelitis,  disseminated 
sclerosis,  amyotrophic  lateral  sclerosis,  hysteria,  diseases  of  the 
brain  that  affect  the  motor  tracts,  such  as  tumors,  vascular 
diseases,  and  the  like,  and  from  Erb's  syphilitic  spastic  spinal 


296  MANUAL   OF   NERVOUS   DISEASES 

paralysis.  From  all  these  diseases  lateral  sclerosis  is  differ- 
entiated by  the  fact  that  it  is  very  slowly  progressive,  and  that 
there  is  a  complete  absence  of  any  other  symptom  than  spastic 
paralysis.  There  are  no  cerebral  symptoms,  no  sensory  symp- 
toms, and  no  bowel  or  bladder  involvement. 

Course  and  Prognosis. — ^The  disease  is  a  slowly  progressive 
one,  extending  over  many  years.  The  prognosis  as  to  recovery 
is  unfavorable,  but  as  to  life  and  usefulness  it  is  good. 

Treatment. — Overexertion  should  be  avoided  and  trauma 
guarded  against.  The  general  health  should  be  maintained  by 
proper  diet,  fresh  air  and  tonics,  and  a  moderate  amount  of 
exercise  is  to  be  advised.  The  spastic  condition  of  the  muscles 
and  the  tendency  to  spasmodic  contractions  of  the  muscles  is 
best  relieved  by  warm  baths,  hot  applications  to  th6  spine, 
massage  of  the  affected  parts,  and  the  administration  of  seda- 
tives. 

ATAXIC   PARAPLEGIA 

This  is  a  chronic  disease  of  the  spinal  cord  characterized  by 
symptoms  that  can  be  referred  to  the  disturbance  of  functions 
of  the  posterior  and  lateral  tracts  of  the  cord. 

Etiology. — This  disease  usually  develops  in  males  after  the 
thirtieth  year.  Trauma,  exposure,  and  overexertion  frequently 
precede  the  disease.  In  individuals  suffering  from  this  disease 
a  marked  anemia  is  usually  present.  Oppenheim  believes  that 
the  anemia  and  loss  of  strength  are  not  the  cause  of  the  disease, 
but  that  the  anemia  and  the  disease  are  both  the  result  of  some 
common  cause,  which  may  be  a  toxin  or  a  micro-organism. 

Marie  traces  this  disease  to  an  endarteritis  in  the  spinal 
vessels. 

Pathology. — Cross-section  of  the  spinal  cord  of  an  individual 
who  has  had  ataxic  paraplegia  shows  degeneration  of  the  column 
of  GoU,  part  of  the  column  of  Burdach,  the  direct  cerebellar 
tract,  and  the  lateral  pyramidal  tract.  The  extent  of  the  in- 
volvement of  these  different  portions  of  the  spinal  cord  varies 
in  different  cases — in  some  cases  the  posterior  columns  are 
affected  more  than  the  lateral,  and  in  others  the  involvement 
of  the  lateral  columns  is  more  marked  than  that  of  the  posterior 


ATAXIC   PARAPLEGIA  297 

columns.  In  the  majority  of  cases  the  dorsal  region  is  first  in- 
volved and  shows  the  most  extensive  lesions. 

Symptoms. — Two  groups  of  symptoms  characterize  this  dis- 
ease, either  of  which  may  be  the  first  to  appear,  and  either  of 
which  may  merge  into  the  other,  depending  upon  whether  the 
posterior  columns  or  the  lateral  columns  show  the  greater  in- 
volvement, and  upon  the  extension  of  the  disease  as  it  advances. 
In  the  first  group  the  symptoms  are  spastic — spinal  paralysis, 
accompanied  by  ataxia,  lightning  pains,  bladder  weakness,  and 
slight  sensory  disturbances,  such  as  loss  of  muscle  sense  and 
incoordination.  In  these  cases  the  disease  begins  with  a  feeling 
of  fatigue  after  mild  exertion,  numbness,  heaviness,  and  stiffness 
in  the  legs,  with  unsteadiness  of  gait,  which  is  usually  worse  in 
the  dark.  There  is  generally  decrease  of  tactile  sensibility  in 
the  feet,  an  exaggeration  of  the  knee-jerks,  and  the  Babinski 
sign  may  be  present. 

In  the  second  group  the  symptoms  are  of  the  tabetic  type. 
The  disease  begins  with  ataxia,  lightning  pains,  and  bowel  and 
bladder  disturbances,  to  which  is  added  a  progressive  paraplegia. 
In  this  group  of  cases  the  onset  is  similar  to  that  of  tabes  dorsalis, 
except  that  it  is  somew^hat  more  rapid,  and  that  the  symptoms 
of  a  paraplegia  are  added. 

As  the  disease  advances  either  the  spastic  or  the  tabetic 
symptoms  may  become  more  prominent,  the  spastic  usually 
predominating  over  the  ataxic  symptoms.  The  case  presents 
an  appearance  similar  to  that  of  lateral  sclerosis  to  which  sensory 
disturbances  are  added. 

Diagnosis. — This  disease  must  be  differentiated  from  multiple 
sclerosis  and  cerebrospinal  syphilis.  From  multiple  sclerosis  it 
is  differentiated  by  the  absence  of  speech  disturbances,  n3^stag- 
mus,  intention  tremor,  etc.  From  spinal  syphilis  it  is  differ- 
entiated by  the  examination  of  the  cerebrospinal  fluid,  the 
presence  of  cerebral  symptoms,  local  pain  and  stiffness  of  the 
back,  and  the  more  rapid  progress  of  symptoms,  w^ith  exacerba- 
tions at  night. 

Course  and  Prognosis. — The  course  of  this  disease  is  usually 
chronic  or  subacute ;  it  may  run  its  course  within  a  few  months  or 
it  may  last  many  years.     It  has  a  tendency  to  spread  from  below 


298  MANUAL   OF   NERVOUS   DISEASES 

upward,  but  may  affect  all  four  extremities  simultaneously. 
The  prognosis  is  grave,  but  not  hopeless,  for  some  of  the  cases 
that  develop  as  the  result  of,  or  during  the  course  of,  anemia  may 
recover. 

Treatment. — In  those  cases  in  which  marked  anemia  exists 
the  treatment  should  be  directed  toward  the  relief  of  this 
condition.  Proper  food,  arsenic  and  iron,  fresh  air,  attention 
to  the  gastro-intestinal  tract,  careful  examination  to  discover  the 
cause  of  the  anemia  and  to  correct  it  if  found  make  up  the  treat- 
ment. Those  cases  in  which  examination  does  not  reveal  a 
cause  are  to  be  treated  by  making  the  patient  as  comfortable  as 
possible  by  means  of  warm  baths,  relief  of  pain,  massage,  and 
attention  to  the  general  health. 

FRIEDREICH'S   DISEASE    (HEREDITARY  ATAXIA) 

This  disease  is  characterized  by  ataxia  developing  in  child- 
hood, and  by  the  fact  that  more  than  one  member  of  the  same 
family  usually  become  affected. 

Etiology. — This  disease  is  due  to  defective  development  of 
the  spinal  cord.  Direct  heredity  is  unusual,  but  a  history  of 
epilepsy,  mental  disease,  alcoholism,  etc.,  in  the  ancestry  is 
generally  present.  In  some  families  one  member  may  be  affected 
with  Friedreich's  ataxia;  brothers  or  sisters  have  either  the  same 
disease  or  suffer  from  epilepsy  or  mental  abnormalities.  The 
disease  may  manifest  itself  first  after  an  infectious  disease, 
injury,  or  malnutrition;  in  some  cases  the  condition  may  be 
congenital.  As  a  rule,  the  symptoms  make  their  appearance 
between  the  sixth  and  the  eighth  year,  but  sometimes  they  do 
not  appear  until  puberty. 

Pathology. — The  spinal  cord  as  a  whole  is  thinner  than  normal, 
and  cross-section  will  usually  show  degeneration  of  the  columns 
of  Goll  and  Burdach,  of  the  direct  cerebellar  tract,  of  Clark's 
column,  and  of  the  pyramidal  tracts.  As  a  rule,  some  fibers  in 
these  tracts  are  spared.  Wherever  nerve-fibers  are  wanting,  a 
thickening  of  the  glia  tissue  is  evident. 

All  investigators  agree  that  this  disease  is  due  to  an  arrest 
of  development  of  the  various  systems  of  fibers  in  the  spinal 


Friedreich's  disease  (hereditary  ataxia)      299 

cord,   being  most  marked    in    the    posterior    portion    of    the 
cord. 

Symptoms. — The  affected  child,  as  a  rule,  shows  a  disturbance 
of  gait;  this  is  uncertain  and  staggering,  and  because  of  this 


Fior.  121. — Friedreich's  ataxia. 


unsteadiness  the  patient  walks  with  the  legs  wide  apart  (Fig. 
121).  If  the  disease  advances  this  ataxic  condition  becomes 
apparent  in  the  attempt  to  maintain  any  position,  such  as  sit- 
ting or  standing;  there  is  a  more  or  less  constant  swaying  of 
the  body  (static  ataxia) .     The  ataxia  spreads  slowly,  and  sooner 


300 


MANUAL   OF   NERVOUS   DISEASES 


or  later  the  upper  extremities  become  affected.  Choreic  move- 
ments sometimes  occur,  and  in  these  patients  involuntary  pur- 
poseless movements  are  made  from  time  to  time,  the  various 
muscles  of  the  body  being  affected.  Muscular  weakness  may 
be  associated  with  ataxia,  but  it  is  only  in  the  last  stages  of  the 


Fig.  12  2. — Friedreich's  ataxia,  showing  lateral  curvature  of  spine. 


disease  that  weakness  becomes  marked;  it  then  may  be  com- 
bined with  contractures  and  atrophy.  As  the  ataxia  increases 
a  certain  rigidity  of  the  legs  begins  to  appear;  this  is  commonly 
attended  by  contracture  of  the  posterior  tibial  group  of  muscles, 
causing  a  talipes  equinus. 


Friedreich's  disease  (hereditary  ataxia)     301 

There  is  also  a  hyperextension  of  the  toes,  especially  of  the 
basal  phalanx  of  the  great  toe,  while  the  terminal  phalanx  is  in 
flexed  position,  giving  rise  to  the  condition  known  as  hammer- toe. 
As  the  disease  progresses  scoliosis  frequently  develops,  and 
eventually  walking  or  standing  alone  becomes  impossible  (Fig. 
122).  The  tendon  reflexes  usually  disappear  early  in  the  disease, 
although  there  are  exceptions  to  this  rule.  Babinski's  sign  can 
sometimes  be  elicited.  Sensory  disturbances  are  not  prominent, 
although  there  may  be  some  decrease  in  the  sense  of  touch  and 
in  the  sense  of  position.  Bowel  and  bladder  disturbances  are 
very  uncommon.  The  speech  of  these  patients  is  usually  slow, 
indistinct,  poorly  articulated,  and  difficult  to  understand.  In 
some  cases,  particularly  after  the  disease  has  lasted  for  some 
time,  the  speech  becomes  very  irregular — some  words  and  sylla- 
bles are  brought  forth  slowdy,  whereas  others  are  enunciated 
rapidly,  resulting  in  jerky  speech.  The  patient  usually  presents 
a  somewhat  stupid  appearance,  and  many  are  incapable  of 
intellectual  development.  Early  in  the  disease  nystagmus 
develops,  which  is  not  apparent  except  on  attempts  to  rotate 
the  eyes  from  side  to  side.  Paralysis  of  the  ocular  muscles  does 
not  occur,  and  there  is  no  disturbance  of  the  pupillary  reflexes. 

Diagnosis. — This  disease  must  be  differentiated  from  multiple 
sclerosis:  multiple  sclerosis  does  not  begin  with  ataxia,  but  if  this 
is  present,  it  is  generally  associated  with  a  spastic  paralysis  and 
with  increase  of  tendon  reflexes;  affections  of  the  ocular  muscles 
are  common  and  are  absent  in  Friedreich's  ataxia.  The  ab- 
normal movements  in  multiple  sclerosis  are  of  an  intentional 
character,  and  in  Friedreich's  ataxia  they  are  of  a  choreic  nature. 
In  multiple  sclerosis  there  are  no  abnormal  movements  while  the 
patient  is  at  rest,  and  in  Friedreich's  ataxia  static  ataxia  is  usu- 
ally present. 

From  hereditary  syphilis  this  disease  is  differentiated  by  the 
fact  that  hereditary  syphilis  is  usually  of  an  acute  or  subacute 
onset;  there  are  marked  remissions  in  the  symptoms,  and  the 
optic  and  oculomotor  nerves  are  frequently  affected.  Ex- 
amination of  the  blood  and  spinal  fluid  will  clear  up  the  diag- 
nosis. 

From  locomotor  ataxia  this  disease  is  differentiated  by  the 


302  MANUAL   OF  NERVOUS   DISEASES 

age  of  onset,  the  frequency  of  bowel  and  bladder  disturbance, 
pupillary  disturbances,  lightning  pains,  and  absence  of  con- 
tractures, nystagmus,  and  speech  disorders. 

From  multiple  neuritis  it  is  differentiated  by  the  mode  of 
onset,  the  presence  of  paralysis  and  of  pain,  the  history  of  the 
case,  the  absence  of  speech  disturbances,  nystagmus,  etc. 

From  Marie's  cerebellar  hereditary  ataxia  it  may  not  be  possible 
definitely  to  differentiate  Friedreich's  ataxia.  The  distinguish- 
ing facts  are  that  Marie's  cerebellar  ataxia  usually  develops 
between  the  twentieth  and  the  thirtieth  year;  it  affects  the  arms 
before  the  legs;  the  characteristic  deformity  of  the  feet  is  not 
present,  whereas  pupillary  disturbances  and  optic  atrophy  are 
frequently  observed. 

Course  and  Prognosis. — This  disease  usually  begins  in  early 
childhood,  runs  a  very  slow  course,  and  may  last  for  many 
years.  As  a  rule,  from  ten  to  fifteen  years  elapse  after  the  onset 
of  the  disease  before  the  patient  becomes  incapable  of  getting 
about  without  assistance;  after  this,  if  the  patient  is  well  cared 
for,  he  may  live  for  many  years  with  a  fair  degree  of  comfort. 
The  prognosis  is  very  unfavorable,  as  no  form  of  treatment  seems 
able  to  arrest  the  progress  of  the  disease. 

Treatment. — This  is  confined  to  looking  after  the  patient's 
general  health  and  to  maintaining  his  nourishment  as  well  as 
possible. 

Marie's  Cerebellar  Hereditary  Ataxia. — This  disease  is  usually 
described  along  with  Friedreich's  ataxia.  It  is  due  to  arrest  of 
developement  of  the  cerebellum.  It  usually  manifests  itself 
about  the  age  of  twenty  years.  The  tendon  reflexes  are  not 
disturbed.  As  a  rule,  oculomotor  paralysis,  especially  ptosis 
and  abducens  palsy,  immobility  of  the  pupils,  optic  atrophy, 
and  cerebellar  ataxia  are  present.  In  some  cases  intention 
tremor  also  occurs. 

Diagnosis  of  this  disease  from  Friedreich's  ataxia  is  not  always 
possible,  and  many  authorities  believe  this  to  be  merely  one  of 
the  types  of  hereditary  ataxia  in  which  there  is  a  prominence  of 
bulbar  and  cerebellar  symptoms.  The  course,  prognosis,  and 
treatment  are  similar  to  those  of  Friedreich's  ataxia. 


LOCOMOTOR   ATAXIA    (tABES    DORSALIS)  303 

LOCOMOTOR  ATAXIA  (TABES   DORSALIS) 

Locomotor  ataxia  is  one  of  the  commonest  diseases  affecting 
the  spinal  cord. 

Etiology. — Chronic  intoxications,  injuries,  infectious  diseases, 
overwork,  exposure  to  cold,  etc.,  are  probably  among  the  pre- 
disposing causes  of  this  disease.  Syphilis  is  certainly  the  causa- 
tive agent  in  practically  all  cases.  There  are  a  few  cases, 
however,  in  which  the  most  careful  examination  fails  to  reveal 
a  preexisting  syphilitic  infection.  In  the  majority  of  instances 
locomotor  ataxia  does  not  manifest  itself  until  within  from  five  to 
fifteen  years  after  the  infection,  and  it  is  also  usually  observ^ed 
that  in  these  cases  the  symptoms  of  the  syphilitic  infection  have 
not  been  very  severe. 

Pathology. — Examination  of  the  nerv^ous  system  of  an  in- 
dividual who  has  been  affected  with  a  moderately  severe  form 
of  locomotor  ataxia  w^ill  show  pathologic  changes  in  the  spinal 
cord,  posterior  roots,  posterior  root  ganglia,  spinal  meninges, 
cranial  nerves,  and,  to  more  or  less  extent,  the  peripheral  ner\^es- 
Degeneration  of  the  posterior  columns  of  the  spinal  cord  is 
present,  varying  in  extent,  and  being  usually  more  marked  in  the 
neighborhood  of  the  posterior  horns  (Fig.  1 23) .  There  are  always 
some  fibers  in  the  posterior  columns  that  escape  this  degenera- 
tion. Many  fibers  in  the  posterior  horn,  especially  those  ending 
around  cells  in  the  column  of  Clark,  also  show  degenerative 
changes.  The  posterior  roots  are  usually  smaller  than  normal, 
and  contain  atrophied  fibers.  In  the  ganglia  of  the  posterior 
roots  many  cells  are  seen  in  different  stages  of  degeneration, 
with  consequent  degeneration  of  their  processes,  and  similar 
degenerative  changes  are  also  seen  in  the  ganglia  of  the  sym- 
pathetic system.  Occasionally  examination  of  the  peripheral 
nerves  also  discloses  degenerated  fibers,  but  these  changes  are 
not  so  constant  as  those  occurring  in  the  spinal  cord.  Along 
with  the  process  of  degeneration  of  the  fibers  in  the  cord  there 
is  an  increase  of  neuroglia,  with  subsequent  sclerosis,  bringing 
about  a  flattening  of  the  posterior  portion  of  the  cord.  The 
meninges  of  the  cord  also  undergo  thickening,  and  there  is  a 
closer  adhesion  between  the  meninges  and  the  cord  than  is 


304 


MANUAL   OF   NERVOUS   DISEASES 


Dorsal  region  showing  degeneration  in  Goll's  tract  in  the  early  stage  of 
locomotor  ataxia  (Oppenheim). 


Dorsal  region  showing  marked  degeneration  of  Goll  and  Burdach  and  Clark's 
column  in  a  well-advanced  case  of  locomotor  ataxia  (Oppenheim). 


,^^      f"?^->->. 


•^  ■.»„»^r-«>* 


Cervical  region  showing  marked  degeneration  of  the  posterior  columns  i.i 
the  terminal  stage  of  a  case  of  locomotor  ataxia  (Oppenheim). 


Fig.  123. — Cross-sections   of   spinal  cord   in  locomotor  ataxia,  stained  by 
Weigert-Pal  method,  showing  degenerated  tracts  light  in  color. 


LOCOMOTOR  ATAXIA    (tABES    DORSALIS)  305 

present  in  normal  conditions.  When  this  affection  extends  to 
the  medulla,  there  is  usually  involvement  of  the  Gasserian 
ganglion,  proximal  root  of  the  fifth  nerve,  and  its  prolongation 
into  the  medulla  and  spinal  cord.  Occasionally  the  ninth  and 
tenth  nerves  are  involved.  In  about  10  per  cent,  of  cases  there 
is  primary  degeneration  of  the  optic  nerve.  The  oculomotor 
nerves  may  be  involved  in  some  cases,  although  their  nuclei 
seem  to  undergo  no  change.  There  are  two  theories  to  account 
for  the  location  of  the  lesion  in  this  disease:  the  first  holds  that, 
as  the  result  of  the  action  of  some  toxic  substance,  the  cells  in 
the  ganglion  on  the  posterior  roots,  the  ganglion  on  the  cranial 
nerves,  or  the  ganglion  of  the  sympathetic  system,  undergo 
varying  degrees  of  degeneration,  and  as  a  consequence  their 
processes,  both  those  which  enter  the  spinal  cord  and  to  a  less 
extent  those  which  go  to  the  peripheral  nerves,  undergo  de- 
generative changes.  No  satisfactory  explanation  has  been 
given  why  those  processes  that  help  form  the  peripheral  nerves 
are  less  affected  than  those  that  enter  the  central  nervous 
system.  The  second  theory  maintains  that  pressure  is  exerted 
upon  the  posterior  roots  at  the  point  of  entrance  into  the  central 
nervous  system  by  a  thickenrag,  with  subsequent  contraction, 
of  the  meninges,  which  has  resulted  from  the  effects  of  pro- 
longed irritation  by  some  toxic  substance;  as  a  result  of  this 
pressure  on  the  posterior  roots  atrophy  occurs,  with  degenera- 
tion of  the  fibers  entering  the  cord.  This  theory  does  not  hold 
in  view  of  the  fact  that  such  a  thickeniag  of  the  meniages  does 
not  exist  in  all  cases  of  locomotor  ataxia. 

Symptoms. — The  s\Tiiptoms  of  locomotor  ataxia  are  very 
numerous.  Nevertheless  certain  symptoms  occur  more  fre- 
quently than  others,  and  whereas  some  are  prone  to  occur  early 
in  the  disease,  others  manifest  themselves  more  frequently  in 
the  later  period  of  the  affection. 

For  descriptive  purposes,  the  disease  is  usually  considered 
as  divided  into  three  stages:  the  initial  stage,  in  which  most  of 
the  subjective  symptoms  are  of  an  irritative  character;  the 
second  stage,  in  which  there  may  be  an  accentuation  or  a  dis- 
appearance of  some  of  the  symptoms  of  the  first  stage,  together 
with  marked  disturbances  of  coordination;  the  third  or  termin<U 


306  MANUAL   OF  NERVOUS   DISEASES 

stage,  which  is  characterized  by  general  physical  disintegration 
and  progressive  loss  of  motor  power. 

First  Stage. — Among  the  early  symptoms,  paresthesias 
are  the  most  common,  the  patient  complaining  of  tingling, 
numbness,  or  formication  in  the  lower  extremities,  or  of  a  feeling 
as  if  there  were  something  soft  under  the  feet  when  he  walks. 
Unusual  sensations  of  heat  or  cold  in  various  parts  of  the  body 
are  felt,  and  there  is  generally  undue  fatigue  upon  slight  ex- 
ertion. These  paresthesias  are  usually  felt  first  in  the  legs,  and 
later  on  in  the  trunk;  in  some  cases  the  upper  extremities  are 
first  affected,  and  there  is  at  times  a  sensation  of  constriction, 
as  if  a  band  or  cord  were  tied  about  the  body.  This  is  known  as 
the  girdle  sensation.  All  these  abnormal  sensations  may  be 
constant  or  intermittent  in  character,  and  may  continue 
throughout  the  disease  or  disappear  during  any  stage. 

Pain. — This  may  be  mild  or  extreme  in  character,  and  some- 
times precedes  other  symptoms  for  a  considerable  period.  The 
pain  is  of  a  sharp,  shooting,  burning  character,  intermittent 
and  paroxysmal  in  occurrence.  These  pains  have  been  termed 
''lightning  pains."  The  pain  does  not  follow  the  course  of  the 
nerves,  but  is  usually  said  to  be  felt  deep  in  the  tissues;  it  is 
frequently  treated  as  rheumatic  before  the  true  nature  of  the 
disease  is  recognized.  The  attacks  of  pain  are  particularly 
prone  to  develop  in  cold,  damp  weather,  may  continue  through- 
out the  disease  or  disappear  at  any  stage. 

Crises. — These  attacks  are  probably  due  to  irritation  of  the 
nerves  or  sympathetic  fibers  which  are  supplied  to  the  affected 
organs,  and  are  similar  in  origin  to  the  paresthesias  and  painful 
attacks  which  affect  the  limbs  and  trunk.  The  gastric  crises  are 
probably  the  more  common  variety.  In  this  condition  there  is 
sudden  severe  pain  in  the  stomach,  accompanied  by  nausea  and 
vomiting,  which  may  continue  for  hours  or  days.  This  form  of 
gastric  disturbance  is  very  intractable,  for  the  stomach  seems 
unable  to  retain  anything.  At  times  the  attacks  of  pain  and 
vomiting  are  followed  by  shooting  pains  in  the  arms  or  lower 
extremities.  The  attacks  terminate  suddenly,  and  are  followed 
by  marked  weakness,  loss  of  weight,  and  considerable  mental 
distress. 


LOCOMOTOR   ATAXIA    (tABES    DORSALIS)  307 

Intestinal  or  rectal  crises  may  accompany  the  gastric  crises. 
These  are  usually  ushered  in  with  severe  pains  in  the  intestines 
and  rectum,  accompanied  by  marked  tenesmus.  These  intes- 
tinal disturbances  are  less  common  than  the  gastric  crises,  and 
are  more  apt  to  occur  later  in  the  disease. 

Laryngeal  Crises. — These  are  marked  by  sudden  severe 
persistent  coughmg  and  difficulty  in  breathing.  The  cough  is 
loud  and  harsh,  and  is  more  or  less  constant.  In  addition  to  the 
great  difficulty  in  breathing  there  is  increased  frequency  of  res- 
piration. The  voice  becomes  hoarse  and  rough.  In  pharyngeal 
crises  there  occur  rapid  movements  of  swallowing,  which  are 
painful  in  character  and  are  followed  by  noisy  belching.  Painful 
disturbances  of  the  functions  of  other  organs  of  the  body  have 
also  been  described. 

A  thorough  and  careful  examination  of  patients  affected  with 
these  different  forms  of  crises  fails  to  reveal  a  cause  for  their 
occurrence,  and  they  have  been  said  to  be  due  to  a  central 
irritation  of  the  sensory  nerves  supplying  the  affected  parts. 

Disturbances  of  bowel  and  bladder  control  are  also  commonly 
complained  of  early  in  the  disease.  In  some  cases  the  bladder 
or  the  rectum  empties  itself  without  the  knowledge  of  the  patient, 
the  first  intimation  of  the  involuntary  movement  being  had 
when  he  feels  the  urine  or  the  feces  on  the  skin.  In  other  cases 
there  is  a  retention  of  urine,  the  patient  being  unconscious  of 
the  fact  that  the  bladder  is  unusually  full,  or  that  it  may 
never  completely  empty  itself.  Marked  constipation  may  oc- 
cur, and  it  may  be  impossible  to  empty  the  rectum  without 
artfficial  assistance.  Increased  or  decreased  or  loss  of  the  sexual 
power  may  occur  in  the  early  stages.  In  the  later  stages  there 
is  usually  complete  impotence. 

Physical  Signs. — In  the  first  stage  the  most  common  physical 
signs  are  Westphal's  sign,  or  loss  of  the  knee-reflex;  Argyll 
Robertson's  sign,  that  is,  reflex  immobility  of  the  pupils  to 
light,  the  accommodation  reflex  being  retained ;  areas  of  decrease 
or  loss  of  tactile  sensibility  on  the  trunk.  Less  commonly  there 
occur  transient  oculomotor  paralysis,  optic  atrophy,  trophic 
disturbances,  deafness,  hypotonia  of  the  muscles,  loss  or  decrease 
of  the  sensation  to  pain  or  tactile  sense,  or  of  both,  in  the  low^er 


3o8  MANUAL   OF   NERVOUS   DISEASES 

extremities,  loss  of  muscle  sense  in  the  lower  extremities,  Rom- 
berg's sign,  etc. 

WestphaVs  Sign. — This  may  appear  years  before  other  symp- 
toms manifest  themselves,  and  is  one  of  the  most  frequent  signs 
occurring  in  the  initial  stage.  Jendrassik's  maneuver  should 
always  be  applied  before  determining  definitely  that  the  knee- 
reflex  is  lost.  The  tendo  Achillis  reflex  is  also  generally  absent. 
The  reflexes  in  the  upper  extremities  are  generally  preserved, 
and  are  often  increased.  In  some  cases  they  disappear  before 
those  of  the  lower  extremities. 

Argyll  Robertson's  Sign. — This  sign  is  present  as  a  very  early 
symptom  in  about  90  per  cent,  of  the  cases  of  locomotor  ataxia. 
It  consists  of  a  loss  of  pupillary  contraction  upon  exposure  to 
light,  with  retention  of  pupillary  contraction  to  accommodation. 
In  testing  for  this  sign  it  is  always  well  to  have  the  patient  look 
at  a  distant  object,  and  then  alternately  expose  the  eye  of  illumi- 
nation and  shield  it  against  it.  Under  normal  conditions  upon 
exposure  to  light  the  pupils  will  contract:  when  the  Argyll 
Robertson's  sign  is  present,  there  is  no  contraction  upon  ex- 
posure to  light.  By  having  the  patient  look  at  a  distant  object 
the  pupillary  contraction  that  occurs  during  the  act  of  accom- 
modation is  eliminated. 

Objective  Sensory  Disturbances. — Frequently  there  is  observed 
early  in  the  disease  the  existence  of  small  areas  of  loss  of  tactile 
sense  upon  the  trunk  (Fig.  124).  These  are  seen  especially  on 
the  back,  beneath  the  shoulder-blades,  and  in  the  lumbar  region. 
These  areas  may  exist  even  when  there  is  no  loss  of  sensation  in 
the  lower  extremities.  Decreased  or  delayed  transmission  of 
pain,  temperature,  or  tactile  sense,  or  all  of  them,  and  loss  of  the 
muscle  sense  in  the  lower  extremities,  always  occur  at  some  stage 
of  the  disease — usually  toward  the  end  of  the  first  stage.  As  a 
result  of  the  disturbance  of  muscle  sense  there  is  a  peculiarity  of 
gait,  known  as  the  ataxic  gait.  This  peculiarity  in  walking 
appears  at  some  period  in  almost  every  case,  and  from  this  the 
disease  has  derived  its  name — locomotor  ataxia.  The  loss  of 
pain  sense  is  usually  found  in  the  lower  extremities,  in  irregular 
areas,  and  may  occur  even  though  tactile  sensibility  is  intact. 
In  other  cases  in  conjunction  with  the  disturbance  of  pain  sense 


LOCOMOTOR  ATAXIA    (tABES   DORSALIS) 


309 


there  is  also  a  loss  of  tactile  sense.  In  the  great  majority  of 
cases  disturbance  of  muscle  sense  is  present;  this  is  especially 
so  in  the  lower  extremities,  the  patient  being  unable  to  distin- 
guish, with  his  eyes  closed,  the  various  states  of  flexion  or  ex- 
tension of  the  great  toes.  As  the  disease  advances  this  dis- 
turbance is  present  in  the  ankle-joint,  knee-joint,  hip-joint,  and 
upper  extremities. 


Fig.  124. — Tactile  disturbance  upon  trunk,  frequently  seen  early  in  disease. 


Romberg's  Sign. — This  consists  of  swaying  of  the  body  w^hen 
the  eyes  are  closed  and  the  feet  are  placed  close  together.  This 
symptom  may  appear  early,  but  is  more  commonly  present  in 
the  later  period  of  the  initial  stage.  As  the  disease  progresses 
the  swaying  occurs  even  when  the  eyes  are  open  and  the  feet 
are  far  apart. 

Muscle  Hypotonia. — In  this  condition  there  are  flaccidity  and 
relaxation  of  the  muscles,  so  that  the  limbs  can  easily  be  over- 
extended or  overflexed.     This  manifestation  is  more  apt  to 


3IO 


MANUAL   OF   NERVOUS   DISEASES 


occur  in  the  lower  extremities,  producing  genu  recurvatum;  it 
may  also  occur  in  other  joints  of  the  lower  extremities  and  in  the 
upper  extremities  or  trunk,  allowing  undue  movements  of  these 
parts  to  take  place.  This  symptom  usually  occurs  in  the  second 
stage  of  the  disease. 

Disturbances  of  the  functions  of  the  cranial  nerves  may  also 
be  among  the  early  or  late  symptoms ;  the  most  frequent  of  these 
is  an  oculomotor  paralysis.  This  is  usually  a  temporary  con- 
dition.    A  permanent  oculomotor  paralysis  is,  as  a  rule,  ob- 


Fig.  125. — Charcot  joints,  both  knees. 


served  only  in  the  later  stages  of  the  disease.  Oculomotor 
paralysis  may  manifest  itself  in  a  ptosis;  as  paralysis  of  the  ex- 
ternal rectus  muscle;  sometimes  in  one  or  more  branches  of  the 
third  nerve,  or  complete  ophthalmoplegia  may  occur.  The 
paralysis  of  the  ocular  muscles  is  usually  irregular,  and  may  in- 
volve one  or  more  muscles  of  one  or  both  eyes.  The  pupils  may 
be  abnormally  small,  or  there  may  be  an  inequality  in  their 
size. 
In  about  10  per  cent,  of  the  cases  a  bilateral  simple  progressive 


LOCOMOTOR  ATAXIA  (tABES  DORSALIS) 


311 


atrophy  of  the.  optic  nerv^es  is  among  the  earliest  symptoms, 
and  usually  leads  to  complete  blindness.  This  may,  for  a  long 
time,  be  the  only  evidence  of  tabes,  and  it  is  only  in  exceptional 
cases  that  it  develops  during  the  late  stage  of  the  disease.  The 
fifth  nerve  may  also  be  affected  in  this  disease,  and  when  this 
occurs  there  may  be  attacks  of  pain,  a  feeling  of  numbness  in 
the  face,  with  disturbance  of  sensation,  particularly  decreased 


Fig.  126. — Charcot  joints,  one  knee. 


perception  of  painful  stimuli  in  the  distribution  of  the  fifth 
nerv^e.  The  symptoms  referable  to  lesions  of  the  ninth  and  tenth 
nerves  are  marked  increase  in  the  pulse-rate,  which  is  found  in 
many  cases  of  tabes,  often  in  the  early  period,  and  cardiac 
crises,  gastric  crises,  laryngeal  crises,  etc. 

Trophic  Disturbances. — Trophic  disturbances  in  the  joints  and 
bones — tabetic  arthropathies — usually  appear  early  in  the  dis- 


312  MANUAL  OF   NERVOUS   DISEASES 

ease,  and  are  not  uncommon.  The  knee-joint,  either  of  one 
or  both  sides,  is  that  most  frequently  affected.  This  disturbance 
may  be  atrophic  or  hypertrophic  in  nature,  and  usually  begins 
suddenly.  There  is  swelling  of  the  joint,  which  also  involves  the 
surrounding  tissue,  and  an  exudate  into  the  joint.  There  is  no 
pain,  redness,  or  fever.  In  the  atrophic 'variety  there  are  more 
or  less  complete  destruction  of  the  cartilage  of  the  joint  and  ex- 
treme mobility,  together  with  luxation  or  subluxation  of  the 


Fig.  127. — Charcot  joints,  one  elbow. 

bones.  In  the  hypertrophic  form  there  is  a  formation  of  new 
bony  tissue,  with  bony  excrescences  in  and  about  the  joint 
(Figs.  125-127). 

The  pathologic  processes  that  take  place  are  closely  related 
to  those  of  arthritis  deformans,  but  may  be  distinguished  from 
them  by  the  absolute  freedom  from  pain.  In  some  instances 
there  is  an  extensive  effusion  into  the  joint,  this  being  rapidly 
reabsorbed,  without  destruction  of  the  articular  ends  of  the 
bones  or  formation  of  new  tissue  taking  place. 


LOCOMOTOR   ATAXIA    (tABES    DORSALIS)  313 

The  explanation  offered  for  the  occurrence  of  these  arthro- 
pathies is  that  they  are  the  result  of  trauma  or  strain,  which, 
owing  to  the  anesthetic  condition  of  the  joint,  is  not  perceived, 
and  consequently  no  effort  is  made  by  the  individual  or  by 
nature  to  shield  or  spare  the  affected  joint.  Furthermore,  there 
being  an  interference  with  the  conduction  of  afferent  stimuli 
from  the  joint  to  the  trophic  center  of  the  cord,  no  well-organized 
effort  is  made  on  the  part  of  nature  to  repair  the  damage  that 
has  been  done,  and  consequently  the  reparative  processes  which 
take  place  are  irregular,  excessive,  or  insufffcient. 

In  some  cases  the  bones  are  abnormally  brittle,  so  that 
fractures  occur  spontaneously.  Perforating  ulcers  develop  quite 
commonly,  usually  on  the  sole  of  the  foot,  in  the  region  of  the 
balls  of  the  toes;  these  show  a  great  tendency  to  penetrate 
deeply,  and  are  very  resistant  to  treatment.  The  skin  may  also 
be  the  seat  of  trophic  disturbances;  thus  there  may  be  herpetic 
eruptions,  thickening  of  the  skin,  or  an  imperfect  growth  or 
falling  out  of  the  nails.  Subcutaneous  ecchymoses  may  be 
present,  and  are  usually  secondary  to  trauma  that  has  not  been 
perceived. 

These  symptoms  and  signs  may  or  may  not  appear  in  the 
early  stage  of  the  disease,  or  they  may  appear  and  disappear 
in  part,  or  become  accentuated  as  the  disease  enters  on  the 
second  stage,  or  this  may  set  in  without  any  of  these  symptoms 
or  signs  having  been  observed.  The  first  evidence  of  the  disease 
may  be  the  appearance  of  the  symptom  most  characteristic 
of  the  SECOND  STAGE — namely,  ataxia. 

Ataxia  may  be  defined  as  an  imperfect  coordination  of  muscu- 
lar action  or  awkwardness  of  movement.  This  incoordination,  in 
the  majority  of  cases,  first  affects  the  muscles  of  the  lower  ex- 
tremities, and  becomes  exaggerated  w^hen  the  control  of  the  eyes 
is  excluded;  consequently  it  is  more  marked  while  walking  or 
moving  about  in  the  dark  and  in  going  down  steps.  Ataxia  in 
the  lower  limbs  produces  the  characteristic  gait  of  tabes.  In 
this  condition  the  steps  are  irregular  in  length ;  the  patient  walks 
with  feet  wide  apart,  and  the  muscular  contractions  are  ex- 
cessive. The  legs  and  feet  are  raised  too  high  from  the  ground, 
and  the  foot  is  brought  to  the  ground  with  excessive  force,  the 


314  MANUAL   or   NERVOUS   DISEASES 

heel  striking  first.  As  the  disease  progresses  ataxia  affects  all 
the  movements  of  the  body.  When  the  patient  rises  from  a 
sitting  position  he  is  apt  to  lean  too  far  forward,  and  upon 
assuming  the  erect  position  he  sways  backward  and  forward 
before  gaining  his  proper  balance. 

These  patients  usually  watch  all  their  voluntary  movements 
carefully,  as  they  are  performed  better  with  the  aid  of  sight  than 
by  depending  upon  the  disturbed  coordination.  The  hands  and 
upper  extremities  may  also  become  ataxic,  when  the  same  pecu- 
liarities and  awkwardness  are  apparent  in  the  movements  of  the 
upper  extremities.  When  ataxia  is  well  developed,  there  is 
commonly  a  marked  disturbance  of  the  deeper  forms  of  sensi- 
bility, such  as  the  pressure  sense,  the  sense  whereby  the  differ- 
ence in  weights  is  perceived,  the  sense  of  position,  etc. 

In  the  second  stage  there  is  an  intensification  of  the  signs 
of  the  first  stage.  There  may  occur  an  accentuation,  a  decrease, 
or  a  disappearance  of  some  of  the  symptoms.  In  this  stage 
there  is  nearly  always  a  loss  of  sensibility.  Areas  of  anesthesia 
are  present  that  correspond  to  the  distribution  of  the  spinal-cord 
segments  and  peripheral  nerves.  There  may  be  a  loss  of  or  a 
marked  delay  in  the  transmission  of  the  various  forms  of  sen- 
sation. 

Pain  and  temperature  sense  are  particularly  apt  to  be  dis- 
turbed. The  muscular  strength  of  the  patient  is  usually  good 
in  this  stage,  although  lack  of  coordination  may  give  rise  to 
a  semblance  of  weakness. 

Third  Stage  of  Paralysis. — The  second  gradually  merges 
into  the  third  stage.  When  the  ataxia  becomes  so  marked,  the 
patient  is  unable  to  leave  his  chair  or  bed.  In  this  stage  the 
signs  and  symptoms  that  have  appeared  in  the  two  previous 
stages  usually  become  exaggerated  in  intensity.  As  a  result  of 
bowel  and  bladder  disturbances,  crises,  attacks  of  pain,  etc., 
there  is  marked  interference  with  the  general  nutrition  of  the 
patient,  and  complications  secondary  to  infection  of  the  bladder 
or  kidneys,  etc.,  may  appear.  The  patient  usually  dies  of  some 
intercurrent  disease.  The  paralysis  is  due  principally  to  the 
marked  ataxia  and  to  the  general  disturbance  of  nutrition. 
If  the  disease  is  not  arrested,  unusual  symptoms  may  appear. 


LOCOMOTOR  ATAXIA    (tABES    DORSALIS)  315 

Among  these  are  mental  disturbances,  attacks  of  hemiplegia, 
epileptiform  seizures,  involuntary  movements,  etc. 

Course. — The  disease  usually  pursues  a  very  chronic  course. 
In  most  cases  the  onset  is  marked  by  symptoms  of  irritation, 
such  as  pain,  paresthesia,  crises,  etc.  A  few  cases  begin  with 
progressive  loss  of  vision,  and  in  a  few  the  first  evidence  of  the 
disease  is  the  ataxia.  The  disease  generally  runs  a  very  pro- 
longed course,  some  symptoms  disappearing  and  others  appear- 
ing as  the  disease  advances. 

An  individual  may  have  tabes  for  many  years  without  being 
conscious  of  the  fact.  The  disease  usually  lasts  from  fifteen  to 
thirty  or  forty  years  if  the  individual  does  not  die  of  an  inter- 
current disease  or  of  some  complication. 

Prognosis. — The  prognosis  as  to  life  is  good  except  in  those 
cases  subject  to  severe  crises,  during  any  one  of  which  the  patient 
may  die  of  exhaustion.  There  is  also  danger  to  life  from  in- 
fection of  the  bladder  and  kidneys,  from  sepsis  the  result  of 
bed-sores,  or  from  injuries  that  are  not  painful,  etc.  The 
prognosis  as  to  arrest  of  the  disease  and  eradication  of  the  under- 
lying syphilitic  infection  is,  in  my  opinion,  ver\'  good  if  the 
proper  treatment  is  instituted.  One  must  remember  that, 
although  it  may  be  possible  to  prevent  the  further  progress  of 
the  disease,  it  is  not  possible  to  restore  to  the  normal  those 
tissues  that  have  been  destroyed ;  consequently  many  s^nrnptoms 
may  be  permanent.  This  last  is  especially  true  of  paresthesia, 
anesthesia,  painful  attacks,  the  various  ph3'sical  signs,  such  as 
pupillary  disturbances,  loss  of  the  knee  reflexes,  etc.  The 
ataxia  can  often  be  overcome  by  a  course  of  muscular  "reeduca-' 
tion." 

Diagnosis. — The  diagnosis  of  tabes,  as  a  rule,  presents  no 
difi5.culty.  The  principal  disease  from  which  it  must  be  differ- 
entiated is  multiple  neuritis,  the  differentiation  being  made  from 
the  history  of  the  onset:  In  multiple  neuritis  the  onset  is  usually 
acute  or  subacute  in  nature,  the  disease  reaching  its  height  in  a 
few  weeks  or  months.  In  tabes  the  onset  is  much  more  gradual. 
In  multiple  neuritis  sensor}^  disturbance,  manifesting  itself  in 
glove-shaped  or  stocking-shaped  areas,  or  along  the  distri- 
bution of  the  peripheral  nerves,  occurs;  in  tabes  the  sensory 


3l6  MANUAL  OF  NERVOUS  DISEASES 

symptoms  affect  the  distribution  of  the  spinal  segments.  In 
multiple  neuritis  there  is  an  absence  of  primary  optic  atrophy, 
Argyll  Robertson  pupil,  bladder  disturbances,  and  girdle  sen- 
sation, whereas  one  or  more  of  these  symptoms  are  practically 
always  present  in  tabes.  In  multiple  neuritis  the  peripheral 
nerves  are  tender  to  pressure  and  there  is  usually  a  degenerative 
paralysis;  in  tabes  the  nerves  are  not  tender  to  pressure,  and 
paralysis  rarely  occurs.  In  multiple  neuritis  there  is  generally  a 
history  of  toxemia,  whereas  in  tabes  syphilis  is  the  basic  factor. 

In  tabes  it  is  extremely  important  that  the  diagnosis  be  made 
early,  although  it  is  only  in  the  early  stage  that  there  is  any 
difficulty  in  making  the  diagnosis.  The  existence  of  any  one  of 
the  following  group  of  symptoms  justifies  a  diagnosis  of  tabes. 
In  the  absence  of  mental  symptoms  an  early  diagnosis  can  be 
made  when  examination  of  the  cerebrospinal  fluid  gives  a 
positive  Wassermann  reaction,  and  this  is  combined  with  any  two 
of  the  following  signs:  Argyll  Robertson  pupil,  Westphal's  sign, 
optic  atrophy,  crises,  Charcot  joints,  bladder  disturbances, 
etc. 

Argyll  Robertson  pupil,  a  positive  Wassermann  reaction  of 
the  cerebrospinal  fluid,  or  Westphal's  sign,  in  conjunction  with 
any  two  of  the  common  symptoms  of  tabes,  practically  justifies 
a  diagnosis  of  tabes. 

The  cerebrospinal  fluid  in  at  least  95  per  cent,  of  cases  of 
tabes  gives  a  positive  Wassermann  reaction,  and  in  addition  to 
this  there  is  a  marked  lymphocytosis.  In  all  cases  in  which 
there  is  any  doubt  as  to  the  diagnosis,  examination  of  the  cerebro- 
spinal fluid  is  of  the  greatest  assistance. 

Treatment. — The  treatment  resolves  itself  into  the  relief  of 
such  symptoms  as  may  exist,  and  in  efforts  directed  toward  the 
arrest  of  the  disease.  Patients  seem  to  do  better  in  dry,  warm 
climates  than  in  moist,  cold  climates.  As  a  rule,  these  patients 
are  hypersensitive  to  cold,  and  they  should,  therefore,  be  given 
only  warm  or  tepid  baths.  The  maintenance  of  the  general 
nutrition  of  the  patient  is  most  important,  and  especial  care 
should  be  directed  toward  this  point.  As  these  patients  tire 
very  easily,  and  as  fatigue  is  injurious,  they  should  be  w^arned 
against  overexertion.     If  there  is  anesthesia  in  any  areas  of  the 


LOCOMOTOR   ATAXIA    (TABES    DORSALIS)  317 

body,  the  patients  should  be  warned  against  exposing  themselves 
to  trauma,  and  all  trilling  injuries  should  be  carefully  and 
promptly  looked  after,  thus  avoiding  the  development  of  more 
serious  conditions.  Proper  attention  should  be  directed  to- 
ward the  bowel  and  bladder  functions,  and  care  should  be  ex- 
ercised that  the  bladder  does  not  become  overdistended.  When 
catheterization  is  necessary,  it  should  be  done  under  aseptic 
precautions.  For  relief  of  the  pain  many  drugs  have  been  used; 
among  these  are  phenacetin,  pyramidon,  aspirin,  and  codein, 
and  eventually,  in  most  cases,  morphin  will  be  resorted  to.  For 
the  various  crises  morphin  and  atropin  in  large  doses  and  coun- 
terirritation  along  the  spinal  column  seem  to  be  of  value.  Con- 
tinuous galvanism  to  the  spine  and  to  the  cervical  sympathetic 
ganglia  has  been  recommended. 

Suspension,  massage,  nerve-stretching,  etc.,  have  all  been  used, 
with  little  or  no  benefit,  x^pparatus  for  supporting  the  spinal 
column  has  no  special  value,  but  where  deformity  or  hypotonia 
exists,  apparatus  for  the  support  of  the  legs  is  recommended. 
Sexual  excesses  are  to  be  avoided.  When  ataxia  is  present,  or 
early  in  the  disease,  if  there  is  awkwardness  of  movement,  a 
system  of  muscular  exercises  recommended  by  Frenkel,  of 
Hayden,  is  of  great  value.  These  exercises  are  very  simple,  and 
when  properly  carried  out,  patients  suffering  even  with  extreme 
ataxia  can  be  reeducated  to  use  their  extremities  in  a  normal 
manner.  In  severe  attacks  of  crises,  when  other  means  have 
failed,  relief  may  be  obtained  by  the  injection  into  the  subdural 
spinal  space  of  a  small  quantity  of  a  25  per  cent,  solution  of 
magnesium  sulphate. 

Foerster  and  Frenkel  have  both  described  a  surgical  procedure 
for  the  cure  of  gastric  crises.  These  operations  are  attended 
with  considerable  risk  and  are  not  always  successful. 

In  view  of  the  results  that  have  been  attained  in  the  past  two 
years  in  the  treatment  of  tabes  by  intraspinous  medication,  there 
can  be  no  question  as  to  the  advisability  of  employing  this  form 
of  treatment.  Before  beginning  the  treatment  a  Wassermann 
examination  of  the  blood  and  cerebrospinal  fluid,  and  a  cell 
count,  globulin  reaction,  etc.,  of  the  spinal  fluid  should  be  made. 
In  those  patients  in  w^hom  a  positive  Wassermann  reaction  of  the 


3l8  MANUAL   or   NERVOUS   DISEASES 

spinal  fluid  is  obtained  the  following  line  of  treatment  is  advis- 
able : 

The  patient  is  given  an  intravenous  injection  of  to  gram 
of  salvarsan.  Within  one  hour  80  ex.  of  blood  are  with- 
drawn, under  the  strictest  aseptic  conditions.  The  serum  is 
separated  from  the  cellular  constituents  of  the  blood  either  by 
centrifuging  or  by  allowing  the  blood  to  stand  for  about  twenty- 
four  hours.  The  serum  is  now  diluted  with  normal  salt  solution 
until  a  60  per  cent,  solution  is  obtained;  to  each  30  c.c.  of  this 
solution  there  is  added  to  grain  of  mercuric  chlorid.  The  serum 
is  now  heated  to  56°  C.  for  half  an  hour.  A  spinal  puncture  is 
made,  and  from  20  to  40  c.c.  of  cerebrospinal  fluid  are  with- 
drawn, and  then,  under  aseptic  precautions,  and  very  slowly, 
the  serum  is  introduced  into  the  subdural  space.  This  treat- 
ment is  repeated  at  intervals  of  from  three  to  four  weeks,  until 
the  cerebrospinal  fluid  gives  a  negative  Wassermann  reaction, 
a  normal  ceU  count,  etc.  In  those  cases  in  which  the  blood  test 
is  positive,  mercurial  inunctions  daily  and  potassium  iodid  in 
increasing  doses  in  the  intervals  between  the  intraspinous  in- 
jections are  indicated.  A  Wassermann  examination  and  a  cell 
count  of  the  cerebrospinal  fluid  withdrawn  should  be  made  before 
the  intraspinous  injection,  so  that  the  effects  of  the  treatment 
may  be  observed.  When  the  spinal  fluid  yields  a  negative  Was- 
sermann reaction  and  a  normal  cell  count,  it  is  safe  to  assume 
that  the  syphilitic  infection  of  the  nervous  system  has  been 
eradicated.  It  is  advisable,  nevertheless,  to  repeat  this  ex- 
amination at  intervals  of  six  months  for  the  following  two  years 
in  order  to  be  certain  that  the  disease  has  been  cured.  As  a 
result  of  these  injections  there  is  usually  a  mild  reaction,  mani- 
fested by  a  slight  rise  of  temperature,  a  feeling  of  general  malaise, 
diarrhea  or  vomiting,  pain  in  the  legs,  and  sometimes  severe 
headache.  This  reaction  rarely  lasts  more  than  twenty-four 
hours.  In  quite  a  number  of  cases  this  method  of  treatment  has 
been  followed  by  marked  improvement  in  the  patient's  general 
condition:  the  lightning  pains,  bowel  and  bladder  disorders, 
disturbances  of  gait,  etc.,  have  disappeared.  This  treatment 
does  not,  however,  restore  to  functional  capacity  that  portion  of 
the  spinal  cord  that  has  been  destroyed  as  the  result  of  the  disease. 


PRESSURE    ON   THE    SPINAL   CORD  319 

Those  symptoms  that  are  due  to  irritation  are  reheved,  and  it 
would  appear  that  the  treatment  arrests  any  tendency  for  the 
disease  to  progress. 

PRESSURE   ON   THE    SPINAL   CORD 

The  spinal  cord  may  be  compressed  as  the  result  of  the  follow- 
ing conditions:  spinal  caries;  malignant  growths  of  the  vertebrae 
or  meninges ;  syphilitic  exudations  into  the  spinal  canal ;  aneu- 
rysms of  the  aorta,  causing  absorption  of  the  vertebral  bodies, 
etc. 

Spinal  Caries. — Etiology. — Tuberculosis  and  injury  are  the 
usual  causes  of  spinal  caries.  Children  are  affected  more  fre- 
quently than  adults,  and  any  portion  of  the  spinal  column  may 
be  involved. 

Pathology. — The  condition  is  almost  always  tubercular  in 
nature,  but  may  occur  after  injury.  It  usually  affects  the 
bodies  of  the  vertebrae  first,  less  frequently  the  joints,  ligaments, 
or  vertebral  arches  and  their  processes.  As  a  result  of  osteitis 
there  is  a  breaking  down  and  softening  of  the  bone,  with  the 
formation  of  a  caseous  or  purulent  infiltrate.  The  process  is 
generally  limited  to  one  vertebra.  If  cure  takes  place,  new 
bone  is  formed  at  the  site  of  the  diseased  process.  If  the  disease 
progresses  there  are  absorption  and  necrosis  of  the  bony  sub- 
stances, with  consequent  collapse  of  the  neighboring  vertebrae, 
or  the  soft,  caseous  material  forms  an  abscess  that  compresses 
the  spinal  cord.  Rarely  is  the  spinal  cord  compressed  by  the 
vertebra  itself  (Figs.  128,  129). 

Compression  of  the  cord  may  also  occur  without  displace- 
ment of  the  vertebrae.  Usually  the  narrowing  of  the  spinal 
canal  takes  place  slowly.  If  there  is  pressure  against  the  dura, 
a  more  or  less  chronic  inflammatory  process  occurs  that  extends 
beyond  the  confines  of  the  diseased  vertebrae,  bringing  about 
marked  increase  of  the  normal  thickness  of  the  dura,  with 
some  bulging  into  the  canal.  This  process  is  generally 
slow  in  advancing.  The  compression  and  obstruction  of  the 
blood  and  lymph-vessels  in  the  membranes  and  cord  produce 
edema  of  the  cord,  which  may  exist  for  a  prolonged  period  with- 


220  MANUAL  OF  NERVOUS  DISEASES 

out  producing  any  marked  alteration  in  the  nerve  elements. 


Fig.  128. — x-Ray  of  spinal  column  in  spinal  caries. 

Sooner  or  later,  if  the  pressure  is  continued,  destruction  of  the 
nerve    elements   follows.     Softening    and    inflammation   bring 


PRESSURE    ON   THE   SPINAL   CORD 


321 


about  a  more  or  less  well-marked  transverse  myelitis.  In  some 
instances  there  is  direct  evidence  of  the  tubercular  infection  of 
the  spinal  cord.  This  is  particularly  marked  around  the  vessels. 
As  a  rule,  the  edema,  softening,  or  myelitis  involves  several 
segments  of  the  cord.  If  the  disease  is  of  long  standing,  signs 
of  secondary  degeneration  are  also  present.  The  nerve-roots 
are  affected  as  a  general  rule,  being  subject  to  pressure  in  the 


•T 


Fig.  129. — Photograph  showing  extensive  spinal  cun,^ature  without  involve- 
ment of  cord.     (Case  of  Dr.  A.  Shipley.) 


spinal  canal  or  in  their  passage   through  the  intervertebral 
foramina. 

Symptoms. — The  general  condition  of  the  patient  is  not  always 
affected.  In  some  cases  there  may  be  constitutional  symptoms 
and  evidence  of  tuberculosis  may  exist  in  another  portion  of  the 
body.  Usually,  the  first  and  one  of  the  most  common  symptoms 
is  pain,  which  is  felt  in  the  region  of  the  affected  vertebrae,  and  is 
increased  on  movement  or  on  pressure.  The  pain  radiates 
along  the  distribution  of  the  nerves  whose  trunks  or  roots  are 


ai 


322  MANUAL   OF   NERVOUS  DISEASES 

involved  in  the  pathologic  process.  The  pain  is  generally  very 
intense,  and  the  patient  endeavors  to  guard  against  all  shocks 
and  avoids  any  unnecessary  movements. 

There  is  rigidity  of  that  portion  of  the  back  that  is  involved  in 
the  pathologic  process.  Deformity  of  the  spinal  column  may 
exist,  or  the  vertebral  disease  may  evidence  itself  by  abscess 
formation  at  some  other  point.  As  the  result  of  pressure  on  the 
cord  two  sets  of  symptoms  occur:  ist.  The  root  symptoms,  which 
consist  of  pain  in  the  distribution  of  the  affected  roots;  this 
pain  may  exist  long  before  other  symptoms  appear.  If  the  dis- 
ease advances,  there  is  added  to  the  pain  atrophic  paralysis, 
with  disturbance  or  loss  of  sensation  in  the  portion  of  the  body 
supplied  by  the  affected  nerves.  2d,  As  the  result  of  pressure  on 
the  cord  there  is  interference  with  the  transmission  upward  and 
downward  of  stimuli.  In  addition  to  the  segmental  symptoms 
and  those  due  to  interference  with  the  transmission  of  impulses 
in  the  cord,  in  severe  cases  there  usually  appear  trophic  dis- 
turbances, such  as  bed-sores,  ulcerations,  etc. 

Diagnosis. — This,  as  a  rule,  presents  no  difficulty.  It  may  be 
formulated  in  the  absence  of  deformity  by  the  presence  of 
tenderness,  spinal  rigidity,  the  root  and  cord  symptoms,  and  by 
means  of  the  x-ray,  which  will  demonstrate  the  presence  of 
disease  of  the  vertebrae.  The  condition  must  be  differentiated 
from  osteomyelitis  vertebralis,  which  usually  runs  a  much  more 
acute  course,  with  high  temperature  and  severe  constitutional 
disturbances,  together,  generally,  with  a  history  of  similar 
affection  in  other  bones  or  of  some  preexisting  focus  of  infection. 
Spinal  caries  must  also  be  differentiated  from  spondylitis  typhosa: 
in  the  latter  condition  the  pains  are  of  unusual  severity,  of  more 
or  less  constant  duration,  and  there  is  a  history  of  typhoid  fever; 
there  is  also  a  rise  in  temperature,  and  very  few  spinal  cord 
symptoms  are  present. 

Course. — The  disease  usually  runs  a  very  chronic  course.  In 
the  majority  of  cases  the  symptoms  of  the  tubercular  bone  condi- 
tion may  long  precede  the  appearance  of  nervous  symptoms. 
In  some  cases,  particularly  in  adults,  the  roots  and  spinal  cord 
symptoms  may  first  give  warning  of  the  presence  of  the  disease; 
in  a  few  cases  the  disease  manifests  itself  suddenly. 


PRESSURE    ON    THE   SPINAL    CORD  323 

Prognosis. — The  prognosis  is  largely  dependent  upon  the 
stage  at  which  the  disease  is  treated,  and  upon  the  thoroughness 
with  which  the  treatment  is  carried  out,  and  also  upon  the  gen- 
eral health  of  the  patient.  If  the  disease  occurs  in  well-nourished 
individuals  and  is  recognized  fairly  early,  under  proper  treat- 
ment the  prognosis  is  very  favorable.  If  the  general  condition 
of  the  patient  is  good,  many  cases  that  have  gone  on  to  paralysis 
and  loss  of  bowel  and  bladder  control,  if  the  sensory  disturbances 
are  not  marked,  may  make  an  almost  complete  recovery.  As 
a  rule,  the  prognosis  is  fairly  good  if  the  patient's  general  condi- 
tion is  good. 

Treatment. — It  is  most  important  to  treat  the  patient's  gen- 
eral condition.  He  should  be  given  plenty  of  fresh  air  and 
good  food.  Climatic  conditions  constitute  a  factor,  and  general 
tonics  should  be  administered.  The  treatment  of  the  spinal 
condition  consists  in  putting  the  parts  at  absolute  rest,  the 
apphcation  of  plaster  jackets,  special  apparatus,  extension,  etc. 
In  those  cases  in  which  the  pressure  upon  the  cord  is  great,  it  is 
frequently  advisable  to  apply  extension  apparatus  for  several 
weeks  or  months.  The  vertebral  bodies  must  be  relieved  of  all 
pressure  and  immobilized  by  the  continuous  use  of  plaster 
jackets  or  braces  for  from  six  months  to  two  years  after  the 
disappearance  of  the  nerve-pressure  symptoms. 

Malignant  Growths  of  the  Vertebrae. — WTien  carcinoma 
appears,  it  is  almost  always  secondary  to  carcinoma  in  some 
other  part  of  the  body,  especially  the  breast.  Sarcoma  and 
osteosarcoma  may  originate  in  the  vertebrae,  but  more  frequently 
they  arise  in  the  vicinity  and  then  invade  the  vertebral  column. 
Other  malignant  growths  may  also  either  originate  in  the  verte- 
bral bodies  or  involve  them  secondarily. 

These  timiors,  whether  originating  in  the  vertebrae  or  arising 
in  the  neighborhood  and  involving  the  vertebrae  secondarily, 
extend  more  or  less  rapidly,  finally  causing  either  direct  pressure 
upon  the  dura  or  spinal  cord  or,  more  commonly,  eroding  the 
dura  and  directly  infiltrating  both  the  membrane  and  the  cord. 
These  tumors  may  develop  at  any  period  of  life,  but  usually 
occur  in  persons  beyond  middle  life,  and  more  frequently  in 
women  than  in  men.    As  a  rule,  the  metastatic  process  is  not 


324  MANUAL   OF  NERVOUS   DISEASES 

limited  to  the  vertebral  column,  but  affects  other  portions  of 
the  body  as  well. 

Symptoms. — Root  Symptoms:  The  earliest,  and  usually  the 
most  prominent  symptom,  is  pain.  This  is  always  very  severe, 
and  is  generally  aggravated  by  movements  or  pressure.  The 
pain  is  of  an  intense,  burning,  shooting  character,  its  situation 
depending  upon  the  location  of  the  tumor.  It  may  be  uni- 
lateral at  first,  but  soon  becomes  bilateral,  and  is  frequently 
attended  by  hyperesthesia,  muscular  twitchings,  and  trophic 
disturbances,  especially  herpes.  As  the  disease  progresses 
evidence  of  spinal  cord  involvement  is  rapidly  added  to  these 
symptoms. 

Here  again  the  symptoms  are  of  two  types,  and  depend  for 
their  distribution  upon  the  particular  portion  of  the  cord  in- 
volved. Segmental  symptoms  are  due  to  the  destruction  of  one 
or  more  segments  of  the  cord,  and  consist  of  flaccid  paralysis, 
loss  of  the  reflexes,  reaction  of  degeneration,  vasomotor  and 
trophic  disturbances,  and  anesthesia.  Tract  symptoms,  which 
are  due  to  the  interference  of  the  transmission  of  impulses 
through  the  cord,  consist  of  weakness  or  paralysis,  loss  of  bowel 
and  bladder  control,  increase  of  the  deep  reflexes,  trophic 
disturbances,  and  disorders  of  sensation. 

The  symptoms  'are  usually  quite  rapid  in  their  advancement. 
The  pain  may  be  so  intense  as  to  give  rise  to  a  marked  hysteric 
condition. 

Diagnosis. — The  diagnosis  is  based  upon  the  patient's  age, 
on  the  history  or  evidence  of  a  primary  growth  elsewhere,  on  the 
marked  pain  in  the  vertebrae  and  in  the  distribution  of  one  or 
two  nerves,  and  on  the  deformity,  if  it  should  exist.  :r-Ray 
examination  is  sometimes  of  value,  as  are  the  comparative 
rapidity  of  the  progress  of  the  symptoms  and  the  absence  of 
tubercular  disease. 

The  prognosis  is  absolutely  unfavorable.  The  course  is 
usually  rapid,  the  duration  being  from  a  few  months  to  a  year. 
Treatment  is  confined  to  relieving  the  patient  of  pain  and  render- 
ing him  as  comfortable  as  possible. 

Aneurysm  of  the  Aorta. — An  aneurysm  of  the  aorta  may  erode 
the  vertebral  bodies  and  gradually  produce  increasing  pressure 


FRACTURE   AND   DISLOCATION   OF    SPINAL   COLUMN      325 

upon  the  spinal  cord.  In  those  cases  in  which  the  evidence  of 
an  aneurysm  of  the  aorta  is  present  and  the  spinal  symptoms 
occur  subsequently  the  diagnosis  is  readily  made.  When  pain 
of  a  neuralgic  character,  followed  by  symptoms  of  pressure  upon 
the  cord,  or  the  symptoms  of  a  superficial  myelitis,  are  the  first 
to  appear,  examination  may  reveal  an  unsuspected  aneurysm  of 
the  aorta. 

Symptoms. — The  symptoms  are  those  of  a  compression  my- 
elitis together  with  the  physical  signs  and  symptoms  of  aneu- 
rysm.   In  these  cases  the  x-ray  is  of  great  value  in  the  diagnosis. 

Syphilitic  Exudations  into  the  Spinal  Canal. — Syphilitic 
involvement  of  the  vertebral  bodies,  while  it  may  occur,  is 
very  rare.  These  syphilitic  exostoses  may  attain  consider- 
able size  and  compress  the  nerve-roots  or  the  cord;  as  a  result 
of  this  pressure  there  may  be  pain  in  the  distribution  of  the 
affected  ner\^e  and  other  pressure  symptoms,  giving  rise  to 
two  types  of  symptoms.  In  addition,  there  may  be  large,  ir- 
regular shaped  exostoses  which  can  be  palpated  in  the  back. 

The  course  is  usually  slow,  and  recovery  follows  proper  treat- 
ment. The  diagnosis  is  made  by  careful  physical  examination 
and  blood  and  spinal  fluid  tests,  etc. 

Treatment. — Rest,  counterirritation,  and  antisyphilitic  medi- 
cation. 

FRACTURE   AND   DISLOCATION   OF  THE   SPINAL 

COLUMN 

Dislocation  occurs  more  frequently  in  the  cervical  region,  and 
comparatively  rarely  involves  the  thoracic  or  lumbar  region. 
The  most  important  of  the  direct  symptoms  of  dislocation  is 
deformity  of  the  spinal  column;  this  is  but  rarely  absent.  The 
spinal  column  is  kept  rigid  by  the  tension  of  the  muscles,  and 
every  attempt  at  movement  is  painful. 

Fractures  of  the  vertebrae  may  occur  in  any  part  of  the  spinal 
column,  and  dislocation  is  frequently  associated  with  the  fracture. 
There  is  usually  marked  displacement,  with  deformity  and 
muscular  rigidity.  In  some  cases  the  fracture  may  be  present 
without  any  visible   deformity.     Occasionally   in   fracture  or 


326 


MANUAL   OF   NERVOUS   DISEASES 


dislocation  the  symptoms  pointing  to  involvement  of  the  nervous 

1 


Fig.  130. — ic-Ray  photograph  of  fracture  dislocation  of  the  spine. 

system  may  be  absent.     As  a  rule,  the  spinal  cord  and  nerve- 
roots  are  involved.     In  some  cases  the  cord  is  compressed  by 


FRACTURE   AND    DISLOCATION    OF    SPINAL    COLUMN      327 

displacement  of  the  vertebrae  or  by  a  fragment  of  bone  that  has 
become  dislodged  and  has  entered  the  spinal  canal  (Fig.  130). 

There  may  be  a  stretching,  crushing,  or  tearing  of  the  cord  as 
the  result  of  excessive  flexion  or  displacement  of  a  portion  of  the 
spinal  column.  After  such  an  injury  there  may  be  no  visible 
evidence  of  the  trauma  inflicted  on  the  spinal  column.  Com- 
pression of  the  spinal  cord  may  also  be  caused  by  hemorrhage 
into  the  membranes  of  the  cord  or  into  the  cord  itself.  It  may 
also  occur  as  the  result  of  the  excessive  formation  of  callus  in  the 
processes  of  repair  at  the  site  of  the  fracture. 

The  spinal  nerve-roots  are  either  compressed  close  to  the  cord 
and  along  with  it,  or  are  crushed  in  their  passage  through  the 
intervertebral  foramina.  The  amount  of  involvement  of  the 
spinal  cord  varies — in  some  cases  the  cord  may  be  extensively 
injured,  and  in  others  very  slight  injury  is  done.  The  symptoms 
depend  upon  the  extent  of  injury  to  the  cord,  subsequent 
involvement  of  the  cord  by  hemorrhage  and  inflammation,  and 
also  on  the  site  of  the  lesion.  In  most  cases  the  cord  is  aft'ected 
at  the  level  of  the  injury  by  compression,  laceration,  hemorrhage, 
and  later  by  inflammation.  Fracture  and  dislocation  of  the 
first  two  cer\^ical  vertebrae  usually  terminate  fatally  either 
immediately  or  within  a  short  time.  Fracture  and  dislocation 
of  the  third  and  fourth  cervical  vertebrae  lead  to  involvement 
of  the  phrenic  nerve;  in  these  cases  life  is  in  great  danger, 
fatal  termination  usually  ensuing  within  a  few  days  or  weeks, 
being  due  to  respiratory  failure,  etc.  In  fractures  or  dislocations 
below  the  fourth  cervical  vertebrae  the  symptoms  pointing  to 
disturbance  of  functions  of  segments  of  the  cord  and  of  the 
conduction  of  impulses  through  these  segments  usually  clearly 
point  to  the  area  of  the  cord  that  is  aft'ected.  In  some  cases  the 
roots  remain  uninjured  and  the  cord  substance  is  involved:  in 
these  patients  the  symptoms  wall  be  situated  low^er  do^vn  on  the 
body  than  the  point  at  which  the  injurv^  occurred,  and  this 
difference  in  the  level  of  injury  and  the  level  of  the  symptoms 
will  be  the  greater  the  lower  down  in  the  vertebral  column  or 
cord  the  site  of  the  injury  is.  In  some  cases  there  is  a  marked 
variation  between  the  distribution  of  the  symptoms  and  the  site 
of  the  spinal  injury:  in  these  cases  the  cord  is  usually  only 


328 


MANUAL   OF   NERVOUS   DISEASES 


partially  affected,  and  there  frequently  exists  a  central  hemor- 
rhage (Figs.  131,  132). 


Fig.  131. — Sensory  disturbance,  weakness,  and  trophic  disturbance 
following  injury  affecting  the  lower  lumbar  region  of  the  cord.  Posterior 
view.     A ,  Area  of  anesthesia. 


When  disease  or  injury  causes  total  interruption  of  the  con- 
duction of  the  cord,  or  if  there  is  a  complete  transverse  destruc- 
tion of  a  segment  or  segments  of  the  cord,  there  will  be  total  loss 
of  motion  and  sensation  below  the  lesion,  and  a  complete  loss  of 


FILA.CTURE   AND    DISLOCATION    OF    SPINAL    COLUMN      329 

all  reflexes — deep,  superficial,  and  organic.  Trophic  disturb- 
ances, especially  bed-sores,  are  apt  to  occur  in  the  portions  of 
the  body  below  the  lesion  if  there  has  been  much  involvement  of 
the  spinal  cord. 

Diagnosis. — It  is  important  to  diagnose  the  degree  of  injury 
to  the  spinal  cord  and  nerve-roots,  and  to  determine  the  exact 


Fig.  132. — Sensory  disturbance,  weakness,  and  trophic  disturbance 
following  injury  affecting  the  lower  lumbar  region  of  the  cord.  Anterior 
view.     N,  Area  of  normal  sensation;  A,  area  of  anesthesia. 


site  of  the  lesion  that  affects  the  spinal  cord.  It  is  sometimes 
very  difficult  to  determine,  within  the  first  few  hours,  the  extent 
of  injury  that  has  been  inflicted  on  the  spinal  cord.  In  some 
cases  the  symptoms  of  cord  involvement  do  not  occur  for  several 
hours  or  days  after  the  injury;  in  other  cases  there  is  complete 


330  MANUAL   OF   NERVOUS   DISEASES 

loss  of  motion  immediately  after  the  injury,  and  sometimes 
marked  interference  with  sensation,  which  rapidly  disappears. 
In  these  two  groups  of  cases  there  is  usually  no  deformity;  the 
symptoms  are  the  result  either  of  a  hemorrhage  into  the  spinal 
canal  or  of  contusion  and  shock. 

In  the  greater  number  of  cases,  immediately  after  the  injury 
there  is  a  disturbance  or  loss  of  motion  and  sensation  and  of 
bowTl  and  bladder  control.  In  extensive  injury  there  are  paral- 
ysis, loss  of  bowel  and  bladder  control,  and  either  complete  or  par- 
tial loss  of  sensation.  In  the  less  severe  degrees  of  injury,  motion, 
sensation,  and  bowel  and  bladder  control  are  involved  to  a  lesser 
extent.  ic-Ray  examination  and  the  distribution  of  the  symp- 
toms are  useful  as  guides  in  locating  the  lesion.  Usually  the 
spinal  cord  is  injured  at  the  site  of  the  fracture  or  dislocation, 
and  is  compressed  either  above  or  below  the  fractured  or  dis- 
located vertebrae. 

Prognosis. — In  cases  of  severe  injury  the  prognosis  as  to  life 
is  very  grave,  the  patients  usually  dying  either  soon  after  the 
injury  oi*  as  the  result  of  secondary  infection  from  bed-sores  or 
from  the  bladder.  The  less  extensive  and  milder  the  symptoms, 
the  better  is  the  prognosis. 

Treatment. — After  a  dislocation  or  fracture  of  the  spine  the 
patient  should  be  moved  as  little  as  possible,  all  unnecessary 
manipulation  of  the  injured  parts  being  avoided.  All  active 
movements  are  to  be  prevented.  Examinations  are  to  be  made 
with  great  care,  and  the  injured  parts  should  be  supported  in 
such  a  way  as  to  preclude  movement. 

Operative  interference  is  of  no  value  in  cases  in  which  the 
symptoms  point  to  complete  transverse  destruction  of  the  cord, 
and  is  to  be  advised  against.  In  those  patients  in  whom  the 
symptoms  point  to  incomplete  interruption  of  conduction  in  the 
cord  there  is  a  great  diversity  of  opinion  as  to  the  advisability 
of  performing  early  or  late  operation,  or  of  avoiding  operative 
interference  entirely.  No  surgical  procedure  is  justifiable  during 
a  condition  of  shock  or  if  there  are  marked  respiratory  symptoms, 
greatly  increased  pulse-rate,  or  temperature  disturbances.  In 
those  cases  in  which  examination  reveals  the  existence  of  pres- 
sure upon  the  spinal  cord  as  the  result  of  bony  displacement, 


TUMORS    OF    THE    SPINAL   CORD  33 1 

etc.,  operation  should  be  done  as  soon  as  the  patient's  general 
condition  permits.  When  the  symptoms  point  to  a  destructive 
condition  of  the  cord  itself,  operation  is  not  to  be  advised. 

Most  surgeons  advise  postponing  operative  procedures  until 
after  the  second  week,  and  then  direct  that  only  those  patients 
be  operated  on  in  whom  there  is  evidence  of  pressure  on  the 
cord. 

In  those  cases  that  are  operated  on,  and  in  those  in  which  an 
operation  has  previously  been  performed,  it  is  advisable  to  keep 
the  back  perfectly  quiet  by  means  of  braces,  a  plaster-of-Paris 
jacket,  etc.,  thus  assisting  nature  in  effecting  union  of  the  broken 
bones  and  preventing  further  deformity,  with  subsequent  com- 
pression or  traction  of  the  cord.  The  greatest  possible  care 
should  be  taken  to  prevent  the  occurrence  of  bed-sores ;  infection 
of  bladder  is  also  to  be  guarded  against,  and  the  bowels  should  be 
emptied  by  means  of  enemata.  Pain  should  be  controlled  by 
analgesics,  and  cramps  and  contractures  are  sometimes  relieved 
by  bromids  and  warm  applications.  The  general  health  of  the 
patient  is  to  be  looked  after,  and  the  muscle  nutrition  should 
be  maintained  by  means  of  massage,  etc. 

TUMORS   OF   THE   SPINAL  CORD 

Tumors  occur  very  infrequently  within  the  spinal  canal.  When 
they  are  present,  they  arise  from  the  meninges  about  twice  as 
often  as  they  do  within  the  cord  itself.  Tumors  developing 
outside  of  the  dura  are  very  rare.  Among  the  tumors  that  rise 
from  the  meninges  are  sarcoma,  endothelioma,  psammoma, 
syphiloma,  tubercle,  fibroma,  myxoma,  etc.  Arising  from  the 
cord  there  are  glioma  and  its  mixed  forms;  outside  of  the  dura, 
with  the  exception  of  those  that  arise  from  the  vertebrae,  are 
the  lipoma  and  cysts.  Malignant  tumors  are  much  more 
frequent  than  benign  tumors  in  this  region.  Intramedullary 
tumors  occur  more  often  in  the  cervical  and  lumbar  enlargement 
of  the  cord,  whereas  meningeal  tumors  occur  chiefly  in  the  dorsal 
region  (Fig.  133). 

Etiology  .^Tumors  of  the  spinal  cord  occur  at  any  age: 
tubercular  tumors  appear  more  frequently  in  childhood,  but  the 


2>d>^ 


MANUAL  OF  NERVOUS  DISEASES 


Other  varieties  occur  at  any  age.     In  many  cases  a  history  of 
injury  precedes  the  development  of  the  tumor. 

Pathology. — Tumors  may  be  multiple,  and  often  involve  both 
the  membranes  and  the  cord.  Sarco?nata  may  appear  either  as 
solitary  or  multiple  tumors;  they  develop  from  the  nervous 
substance  itself  or  from  the  membranes,  and  may  be  confined  to 


Fig.  133. — Spinal  tumor,  gliosarcoma,  which  was  situated  in  lower  dorsal 
and  lumbar  region  of  the  cord;  occurring  in  a  case  in  the  neurologic  service 
at  University  of  Maryland  Hospital;  successfully  removed  by  Dr.  R.  Winslow. 


the  membranes,  forming  nodules,  or  they  may  spread  diffusely 
over  the  surface  of  the  cord.  Sarcomata  more  commonly  com- 
press than  destroy  the  cord,  and  usually  extend  rather  rapidly; 
they  are  often  associated  with  sarcoma  of  some  other  portion  of 
the  body. 

Tubercle  is  more  likely  to  develop  within  the  cord,  when  it 
frequently  occurs  as  a  solitary  tumor,  having  its  origin  usually 


TUMORS    OF    THE    SPINAL    CORD  333 

in  the  gray  matter.  There  is  a  great  tendency  for  these  tumors 
to  recur  after  removal,  and  there  is  also  marked  danger  of  in- 
fection of  the  meninges.  Their  presence  is  frequently  compli- 
cated by  a  tuberculous  meningitis.  Lipojnata  are  congenital. 
Fibromata  originate  within  the  meninges,  and  do  not  invade  the 
cord;  they  are  usually  encapsulated  and  grow  very  slowly. 
Gumma  commonly  originates  in  the  meninges,  and  infiltrates 
and  frequently  destroys  the  cord;  it  is  diffuse  and  grows  rapidly. 

Myxoma  never  infiltrates  the  spinal  cord;  it  is  single,  en- 
capsulated, and  of  slow  growth. 

Glioma  is  an  infiltrating  tumor  of  the  cord.  It  may  or  may 
not  cause  enlargement  of  the  cord,  and  is  distinguishable  only 
microscopically.  It  usually  grows  rapidly  and  is  frequently 
associated  with  sarcoma. 

Tumors  of  the  cord  are  usually  small,  but  if  they  grow  in  a 
vertical  direction,  they  may  attain  considerable  size.  Tumors 
of  the  menmges  cause  compression  of  the  adjacent  roots,  and 
press  upon  the  cord — some  in  front  and  some  behind.  The 
histologic  changes  show  that  the  central  parts  of  the  spinal  cord 
often  suffer  from  the  compression  more  than  the  external  portion. 
The  changes  that  take  place  within  the  cord  are  degeneration 
and  softening  in  the  region  of  the  tumor. 

Symptoms. — Root  s\Tnptoms  are  usually  the  first  evidence  of 
the  existence  of  a  spinal  tumor.  These  symptoms  are  character- 
ized by  intense,  persistent,  sharp,  shooting  pain  in  the  distribu- 
tion of  one  or  tw^o  ner\^es.  These  pains  are  generally  unilateral, 
but  may  be  bilateraL  The  pain  is  often  increased  on  exertion 
or  on  making  violent  unexpected  movements.  The  location  of 
the  pain  is  dependent  on  the  position  of  the  tumor,  it  being  felt 
in  that  part  of  the  body  related  to  the  segment  or  ner^x-roots 
first  affected.  In  tumors  developing  within  the  cord,  or  even 
in  some  tumors  developing  from  the  meninges,  these  pains  may 
be  absent.  The  most  persistent  pains  may  later  on  disappear 
entirely,  or  the  painful  stage  may  persist  for  several  months  or 
even  years  before  other  symptoms  pointiag  to  direct  involve- 
ment of  the  spinal  cord  manifest  themselves.  There  is  generally 
an  area  of  h}'peresthesia  in  the  region  of  the  trunk  supplied  by 
the  segments,  immediately  above  the  affected  one. 


334  MANUAL   OF   NERVOUS   DISEASES 

There  is  rarely  any  rigidity  of  the  spinal  column,  and  pressure 
does  not  increase  the  pain.  If  the  growth  increases  in  size  and 
the  compression  destroys  the  nerve-roots  or  the  spinal  cord,  two 
sets  of  symptoms  arise:  the  one  set  in  the  distribution  of  the 
spinal  segment  or  segments  affected,  and  the  other  set  due  to 
interference  through  the  affected  segments  of  the  impulses  from 
above  or  below.  The  first  set  of  symptoms  consists  of  a  flaccid 
paralysis  of  the  muscles  supplied  by  the  nerves  which  originate 
in  these  segments,  loss  of  the  reflexes  which  take  place  through 
these  segments,  abolition  or  decrease  of  sensation  in  the  portion 
of  the  body  whose  sensory  nerves  correspond  to  the  affected 
segments,  trophic  disturbances,  such  as  herpes,  ulceration, 
vesicles,  etc. 

The  symptoms  due  to  interference  with  the  transmission  of 
impulses  through  the  cord;  if  the  site  of  the  tumor  is  above  the 
lumbar  region,  there  will  occur,  in  the  portion  of  the  body 
corresponding  to  the  portion  of  the  cord  below  the  tumor,  a 
spastic  condition  of  the  muscles,  with  weakness  or  paralysis, 
marked  increase  of  the  deep  reflexes,  and,  if  the  tumor  involves 
one  side  of  the  cord  more  than  the  other,  the  weakness,  increased 
reflexes,  etc.,  are  more  marked  on  that  side. 

Sensibility  may  remain  unaffected  for  a  considerable  time, 
but  if  the  compression  continues,  decrease  and  loss  of  sen- 
sation in  the  portion  of  the  body  below  the  lesion  gradually 
develop. 

In  those  cases  in  which  the  tumor  affects  principally  one  side 
of  the  cord,  sensory  disturbances,  in  which  there  is  loss  of  tem- 
perature sense,  pain  sense,  and  partial  tactile  sense,  will  occur  on 
the  side  opposite  to  that  affected  by  the  motor  weakness,  and  on 
the  side  where  the  motor  weakness  exists  there  will  be  a  loss  of 
muscle  sense,  thus  giving  rise  to  the  Brown-Sequard  syndrome 
(Fig.  134). 

There  is  usually  an  early  impairment  of  the  control  of  the 
bladder  and  rectum,  and  as  the  compression  advances  this  is 
eventually  completely  lost.  As  soon  as  the  sensory  disturbances 
become  marked  there  is  a  tendency  to  the  development  of  bed- 
sores. 

In  tumors  that  compress  the  lumbar  cord  the  root  symptoms 


TUMORS    OF    THE    SPINAL    CORD 


335 


play  a  prominent  part,  for  the  nerve-roots  are  thickly  grouped 
here  and  a  small  tumor  may  press  upon  a  large  number  of  roots. 


Fig.  134. — Brown-Sequard  syndrome  lesion  involving  spinal  cord  in 
middorsal  region,  left  side.  (— i)  Area  in  which  there  is  loss  of  all  forms  of 
sensation,  vasomotor  and  trophic  disturbance,  loss  of  deep  reflexes,  and 
flaccid  motor  paralysis.  (+)  Area  over  which  there  is  loss  of  tactile,  pain, 
and  temperature  sense,     (o)  Area  over  which  there  is  loss  of  muscle  sense, 

partial  tactile  sense,  and  in  which  there  is  spastic  motor  paralysis.     ( ) 

Area  of  cutaneous  hyperesthesia. 


The  pain  affects  the  lower  abdomen,  the  pelvis,  and  the  legs-. 
The  symptoms  caused  by  compression  of  these  roots,  as  well  as  of 


336  MANUAL  OF  NERVOUS  DISEASES 

the  lumbar  enlargement,  are  a  flaccid,  atrophic  paralysis,  with 
loss  of  reflexes,  decrease  or  loss  of  sensation,  bowel  and  bladder 
disorders,  and  trophic  disturbances. 

Tumors  of  the  cauda  equina  cause  great  pain  in  the  region 
of  the  sacrum,  radiating  into  the  perineum,  bladder,  and  the 
sciatic  nerves.  To  these  pains  are  added  atrophic  paralysis, 
limited  to  the  bladder  and  the  muscles  supplied  by  the  nerves  of 
the  sacral  plexus;  disturbance  of  sensation  of  the  perineum  and 
the  segments  of  the  body  corresponding  to  the  sacral  segments 
of  the  cord. 

In  multiple  and  diffuse  tumors  the  symptoms  usually  point  to 
involvement  of  several  segments  of  the  cord. 

The  symptoms  of  tumor  of  the  cord  resemble  those  of  a 
transverse  myelitis  of  gradual  onset,  combined  with  persistent 
neuralgic  pains  in  the  distribution  of  the  posterior  roots  of  the 
affected  segments. 

The  course  of  the  disease  is  a  chronic  one.  It  generally  begins 
with  pain,  which  is  persistent,  and  which  is  usually  unilateral, 
weakness  on  one  side  of  the  body  below  the  lesion,  followed  by  a 
paraplegia,  to  which  are  later  added  the  symptoms  of  a  pro- 
gressive transverse  myelitis.  Death  occurs  from  infection,  cys- 
titis, cachexia,  etc.,  the  disease  running  its  course  in  from  a 
few  months  to  several  years,  depending  upon  the  character  of 
the  growth  and  the  rapidity  of  its  development. 

Diagnosis. — ^The  diagnosis  of  tumors  of  the  spinal  cord  should 
be  made  as  early  as  possible,  for  it  is  only  before  destructive 
conditions  of  the  spinal  cord  have  developed  that  we  can  hope  to 
secure  a  favorable  outcome  after  the  growths  have  been  success- 
fully removed.  The  diagnosis  of  the  presence  of  a  growth  must 
first  be  made;  second,  the  probable  character  of  the  growth 
must  be  determined;  third,  the  location  of  the  growth  must  be 
ascertained,  and  fourth,  it  must  be  learned  whether  it  is  single 
or  multiple.  Tumor  of  the  cord  must  be  differentiated  from 
spinal  syphilis :  in  spinal  syphilis  the  onset  is  more  rapid  and  the 
course  is  intermittent,  with  a  tendency  to  sudden  exacerbations 
and  remissions.  The  symptoms  usually  indicate  lesions  at 
various  sites  in  the  spinal  cord  or  brain. 

The  physical  examination,  the  Wassermann  test  of  the  blood 


TUMORS    OF    THE    SPINAL    CORD  337 

and  spinal  fluid,  and  the  result  of  antisyphilitic  medication  all 
assist  in  making  the  differential  diagnosis. 

The  differentiation  between  tumors  of  the  spinal  cord  and 
caries  of  the  spinal  column  is  made  by  the  presence  of  rigidity, 
tenderness  on  pressure,  increase  of  pain  on  motion,  general 
constitutional  disturbances,  etc.,  which  are  present  in  spinal 
caries  and  absent  in  tumor  of  the  cord.  x-Ray  examination  is 
also  of  value. 

The  presence  of  the  tumor  or  the  history  of  a  previous  opera- 
tion for  removal  of  tumor  of  some  portion  of  the  body  is  always 
of  importance. 

The  variety  of  tumor  can  rarely  be  determined  until  after  its  re- 
moval. By  taking  into  consideration  the  fact  that  some  growths 
are  of  more  rapid  development  than  others;  that  some  occur 
more  frequently  within  the  cord  substance,  whereas  others  origin- 
ate more  commonly  within  the  meninges,  it  is  possible,  before 
operating  and  during  life,  to  hazard  a  tentative  opinion  as  to  the 
character  of  the  growth. 

The  location  of  the  tumor  is  to  be  diagnosticated  by  the  dis- 
tribution of  the  symptoms  corresponding  to  the  affected  segment, 
and  by  the  presence  of  symptoms  pointing  toward  interference 
with  impulses  through  the  cord  at  the  affected  segment. 
Whether  one  or  more  tumors  exist  wall  be  shown  by  the  presence 
of  symptoms  pointing  to  segmental  involvement  at  more  than 
one  level  of  the  cord. 

It  is  important  to  determine  whether  we  are  dealing  with  a 
vertebral,  meningeal,  or  medullary  tumor.  In  vertebral  tumors 
i^-ray  examination,  deformity  of  the  spinal  column,  pain  on 
movement  of  the  spinal  column,  and  the  fact  that  these  tumors 
are  usually  secondary  to  malignant  tumors  elsewhere  usually 
guide  one  to  a  correct  diagnosis.  Meningeal  tumors  generally 
begin  with  root  pains,  flaccid  paralysis  in  the  distribution  of  the 
affected  segment,  and  gradual  development  of  symptoms  point- 
ing toward  compression  of  the  cord;  furthermore,  meningeal 
growths  rarely  extend  upward,  so  that  the  upper  limit  of  the 
segmental  symptoms  remains  unchanged.  In  tumors  of  the 
cord  substance  itself  the  root  symptoms  are  not  prominent  and 
may  be  absent  entirely,  the    symptoms  resemble  those   of  a 


^^S  MANUAL   OF   NERVOUS   DISEASES 

chronic  myelitis,  the  course  is  usually  irregular,  and  there  may 
be  a  sudden  appearance  of  new  symptoms,  due  to  hemorrhage 
into  the  tumor. 

In  diagnosing  the  location  of  a  spinal  tumor  it  must  always 
be  remembered  that  the  pain  and  anesthesia,  which  are  the  most 
reliable  indications  of  the  level  of  the  tumor,  will  be  the  same  in 
a  lesion  of  a  segment  as  in  a  lesion  of  its  nerve-roots  at  a  point 
somewhat  lower  down  within  the  spinal  canal.  It  is,  therefore, 
advisable  to  examine  the  cord  at  a  slightly  higher  level  than  the 
lesion  would  lead  one  to  expect  to  find  it.  It  is  also  important 
to  learn  opposite  which  spinous  processes  the  various  segments 
of  the  cord  are  situated. 

Chipault  has  given  a  practical  set  of  rules  for  determining  the 
relation  of  the  segments  of  the  cord  to  the  spinous  processes  of 
the  vertebrae.  In  the  cervical  region,  add  i  to  the  number  of 
the  vertebrae:  this  will  give  the  segment  opposite  to  it;  in  the 
upper  dorsal  region  add  2 ;  from  the  sixth  to  the  eleventh  dorsal 
vertebrae,  add  3.  Opposite  the  eleventh  dorsal  process  and  the 
space  below  it  are  the  lower  three  lumbar  segments;  opposite 
the  twelfth  dorsal  spinous  process  and  the  space  below  it  are  the 
sacral  segments.  The  spinal  cord  ends  opposite  the  body  of  the 
first  lumbar  vertebra :  below  this  the  spinal  canal  is  occupied  by 
the  Cauda  equina.  This  set  of  rules  applies  only  to  adults.  In 
infancy  and  childhood  the  spinal  cord  extends  lower  down  into 
the  spinal  canal,  and  these  figures  are  not,  therefore,  altogether 
accurate. 

Prognosis. — In  tumors  of  the  cord  the  prognosis  is,  as  a  rule, 
grave,  unless  surgical  intervention  be  undertaken.  If  they  are 
of  tubercular  nature,  the  outcome  in  practically  all  cases  is  fatal. 
In  a  few  benign  tumors  there  may  be  a  spontaneous  arrest  of 
growth.  Cord  tumors  of  syphilitic  origin  may  respond  to 
treatment.  The  greater  number  require  surgical  intervention. 
Diffuse  intramedullary  tumors  cannot  be  removed,  and  the 
outcome  is  fatal.  If  the  diagnosis  is  made  early  and  surgical 
intervention  is  attempted  the  prognosis  is  more  favorable. 

Treatment. — In  those  cases  in  which  pain  is  a  prominent 
symptom  it  will  be  found  that  while  the  coal-tar  products  at 
first  afford  some  relief,  morphin  will  eventually  have  to  be  used. 


SPINAL    MENINGITIS  339 

In  cases  in  which  syphilis  is  suspected,  antisyphilitic  measures 
may  be  tried,  and  if  prompt  relief  does  not  follow,  recourse  should 
be  had  to  operative  intervention. 

When  the  tumors  are  multiple,  or  when  the  growth  is  secondary 
to  a  tumor  in  some  other  portion  of  the  body,  and  likewise  in 
those  cases  that  originate  in  the  vertebral  body,  operation  is 
contra-indicated.  When  but  a  single  growth  is  present,  and  if 
this  can  be  localized  with  some  degree  of  accuracy,  early  operation 
is  to  be  advised.  In  the  hands  of  a  skilful  surgeon  the  operation 
is  not  a  very  difficult  one,  and  can  be  undertaken  with  the 
assurance  that  very  little  damage  is  done  even  if  no  growth  is 
found.  In  those  cases  in  which  there  is  a  meningeal  growth 
that  has  not  infiltrated  but  only  compresses  the  cord,  the  out- 
come is  good  if  the  operation  is  undertaken  early  and  is  properly 
done. 

SPINAL   MENINGITIS 

Acute  spinal  leptomeningitis  is  seldom  a  primary,  isolated 
disease.  It  may  be  of  traumatic  origin.  As  a  rule,  the  infection 
extends  upward  and  involves  the  membranes  of  the  brain.  The 
inflammation  may  be  limited  to  the  spinal  meninges,  as  after 
injury,  various  diseases  of  the  spinal  column,  especially  tuber- 
culosis and  malignant  diseases.  It  may  also  occur  as  an  exten- 
sion of  an  otitic  meningitis,  after  surgical  operations  upon  the 
spinal  column  or  the  cord,  as  a  complication  m  spinal  anesthesia, 
as  the  result  of  extension  of  a  syphilitic  process,  from  bed-sores, 
exposure  to  cold,  etc.  Most  commonly  it  is  secondary  to  the 
presence  of  an  infectious  agent  in  the  blood,  following  pneumonia, 
t}^hoid  fever,  tonsillitis,  septicemia,  etc. 

Pathology. — Upon  opening  the  spinal  canal  an  exudate  of 
serous,  fibrosanguineous,  or  purulent  character  is  seen  deposited 
in  the  network  of  the  pia-arachnoid. 

The  cerbrospinal  fluid  is  turbid.  The  meninges  are  covered 
with  the  exudate,  and  in  places  are  more  or  less  adherent.  The 
blood-vessels  are  distended,  and  many  small  hemorrhages  may 
be  found.  On  microscopic  examination  there  will  be  seen  con- 
gestion of  the  finer  blood-vessels  of  the  meninges  and  the  arteries 
entering  the  cord,  a  serous  exudation  about  the  blood-vessels, 


340  MANUAL   OF   NERVOUS  DISEASES 

both  in  the  pia  and  in  the  cord,  and  swelling,  congestion,  and 
thickening  of  the  pia.  The  nerve-roots  and  the  superficial 
tissues  of  the  spinal  cord  are  also  usually  involved  in  this  in- 
flammatory process,  and  show  some  evidence  of  degeneration, 
which  is  most  marked  about  the  blood-vessels.  The  posterior 
portions  of  the  spinal  membranes  are  generally  more  severely 
affected  than  the  anterior. 

In  tubercular  meningitis  the  spinal  fluid  is  usually  clear  and 
there  is  little  or  no  exudate;  if  any  is  present  it  is  of  a  gelatinous 
nature.  Miliary  tubercles  may  be  found  in  the  membrane, 
especially  in  the  neighborhood  of  the  blood-vessels.  The  patho- 
logic changes  are  usually  diffuse,  but  if  the  disease  extends 
downward  from  the  brain,  the  inflammatory  changes  may  be 
limited  to  the  upper  portion  of  the  spinal  canal. 

Symptoms. — The  onset  is  usually  sudden,  with  chill,  high 
fever  of  irregular  type,  and  marked  constitutional  disturbances. 
Accompaning  or  following  these  symptoms  there  is  acute  pain  in 
the  back,  which  is  increased  by  movement.  The  pain  radiates 
about  the  body  and  into  the  extremities,  and  there  is  stiffness  in 
the  back  and  neck,  which  may  result  in  opisthotonus.  Tonic 
contractures  of  the  muscles  of  the  back,  abdomen,  and  extrem- 
ities are  present.  Pain  and  stiffness  are  increased  when  attempts 
are  made  to  move  the  patient.  In  addition,  there  are  hyperes- 
thesia of  the  skin ;  exaggeration  of  the  cutaneous  and  abdominal 
reflexes;  clonic  tremors  of  the  trunk  and  extremities,  especially 
upon  handling  the  patient;  the  Kernig  sign,  etc.  As  the  disease 
advances  weakness  or  paralysis  develops,  disturbance  of  sen- 
sation takes  place,  bowel  and  bladder  control  is  interfered  wdth, 
and  there  is  a  tendency  to  the  developement  of  bed-sores. 
Vasomotor  disturbances  are  common,  and  there  may  be  cardiac 
and  respiratory  symptoms. 

The  course  is  acute  and  usually  rapid;  within  a  week  there  is 
marked  involvement  of  the  respiratory  and  cardiac  functions. 
In  the  majority  of  cases  the  meningitis  extends  into  the  cranial 
cavity,  and  cerebral  symptoms  develop.  In  other  cases  the 
progress  may  be  slower,  and  several  weeks  may  pass  before  the 
symptoms  become  alarming.  Some  patients  pass  through  the 
acute  stage,  which  may  last  several  weeks,  without  manifesting 


CHRONIC    MENINGITIS  341 

alarming  symptoms;  then  the  meningitis  becomes  chronic,  the 
symptoms  continuing  to  be  present  for  several  months. 

Diagnosis. — ^The  diagnosis  is  made  by  lumbar  puncture  and 
examination  of  the  spinal  fluid,  in  conjunction  with  symptoms 
pointing  toward  involvement  of  the  spinal  meninges. 

Prognosis. — The  prognosis  of  acute  meningitis  is  always  grave. 
In  the  tubercular  variety  recovery  does  not  seem  possible. 
Those  forms  that  are  secondary  to  pneumonia,  typhoid  fever,  etc., 
if  they  remain  limited  to  the  spinal  meninges,  usually  recover. 
The  form  due  to  the  Diplococcus  intracellularis  will  generally 
recover  under  proper  treatment. 

Treatment. — Absolute  rest  in  bed.  It  is  advisable  for  the 
patient  to  lie  upon  the  side,  rather  than  upon  the  back.  An 
ice-cap  or  counterirritation  should  be  applied  to  the  spine. 
General  constitutional  disturbances  should  receive  proper 
treatment.  The  bowels  should  be  kept  well  open,  and  elimina- 
tion encouraged  by  the  free  drinking  of  water.  Pains  are  to  be 
relieved  and  restlessness  is  to  be  combated  by  such  drugs  as  the 
bromids,  codein,  opium,  etc. 

The  patient  is  to  be  guarded  against  the  development  of  bed- 
sores. Spinal  puncture  is  to  be  employed  both  for  diagnostic 
and  for  therapeutic  purposes.  In  those  cases  due  to  the  Diplo- 
coccus intracellularis  antimeningococcus  serum  is  to  be  given. 

CHRONIC   MENINGITIS 

Rarely  acute  meningitis  may  become  chronic.  In  these  cases 
the  meninges  become  opaque,  thickened,  and  generally  adherent 
to  each  other  and  to  the  cord.  The  changes  may  be  localized  or 
extend  throughout  the  entire  cord.  In  the  majority  of  cases 
a  low-grade  chronic  myelitis,  limited  to  the  periphery  of  the 
cord,  is  also  present. 

Another  form  of  chronic  meningitis  is  of  syphilitic  origin. 
In  this  variety  there  is  a  gummy  or  gelatinous  exudate  in  the 
meshes  of  the  pia  and  arachnoid,  very  often  involving  the  nerve- 
roots  as  well.  Thickening  of  the  vessels  and  infiltration  of 
round  cells  are  usually  present.  The  lesions,  both  of  the  men- 
inges and  of  the  cord,  may  be  scattered  irregularly  throughout 
the  entire  cord,  and  may  vary  in  extent. 


342  MANUAL   OF   NERVOUS   DISEASES 

Symptoms. — ^The  onset  of  the  disease  is  slow,  and  it  usually 
runs  a  prolonged  course.  There  is  an  absence  of  general  con- 
stitutional symptoms.  Pain  is  present,  radiating  in  the  dis- 
tribution of  the  spinal  nerves,  and  hyperesthesia,  stiffness  in  the 
back,  a  tendency  to  convulsive  movements,  disturbance  of 
sensation,  weakness  or  paralysis,  disturbance  in  .the  control  of 
the  bowels  and  bladder,  etc.,  are  also  seen. 

Diagnosis. — The  diagnosis  is  made  from  the  history  of  pre- 
existing acute  attacks,  or  if  the  condition  is  of  a  syphilitic 
nature,  by  examination  of  the  blood  and  spinal  fluid. 

Treatment. — ^The  cautery  applied  to  the  spine,  massage,  long- 
continued  warm  baths,  the  alternate  application  of  hot  and  of 
cold  water  to  the  spine,  the  promotion  of  the  general  nutrition 
of  the  patient  by  proper  food,  fresh  air,  and  tonics  are  the  in- 
dications. Inunctions  of  mercury  and  potassium  iodid  in- 
ternally are  of  value  in  all  forms  of  the  disease.  In  those  cases 
that  are  of  syphilitic  nature  the  intravenous  administration  of 
salvarsan,  and  if  the  spinal  fluid  gives  a  positive  Wassermann 
reaction  the  intraspinous  injection  of  salvarsanized  and  mer- 
curialized serum  are  indicated. 

HYPERTROPHIC    PACHYMENINGITIS 

This  is  a  chronic  inflammation,  affecting  chiefly  the  inner  layer 
of  the  dura  mater,  producing  a  laminated  deposit  of  fibrous 
tissue  on  the  dura,  and  causing  it  to  become  markedly  thickened. 

Etiology. — Exposure  to  cold,  overexertion,  trauma',  alcoholism, 
tuberculosis,  and  especially  syphilis  must  be  included  among  the 
causes.  In  the  majority  of  cases  several  factors  are  responsible. 
A  history  of  syphilis,  alcoholism,  and  trauma  is  present  in  the 
greater  number  of  cases. 

Pathology. — ^There  is  a  fibrous  thickening  of  the  dura,  the 
newly  formed  membranes  being  arranged  in  layers.  The  pia 
and  arachnoid  play  a  very  important  part  in  the  inflammation, 
which  frequently  originates  in  these  membranes.  As  a  result 
of  the  thickening  of  the  meninges  there  is  produced  compression 
of  the  cord  and  of  the  nerve-roots.  Not  uncommonly  hemor- 
rhages occur  into  this  newly  formed  tissue  or  upon  its  inner  sur- 


HYPERTROPHIC    PACHYMENINGITIS  343 

face.  New  blood-vessels  are  formed  in  this  tissue,  and  these 
are  very  thin  and  rupture  easily.  This  tissue  causes  compression 
of  the  spinal  cord  and  its  blood-vessels,  and  as  a  result  myelitis 
or  softening  takes  place.  The  exudation  may  be  confined  to  the 
upper  or  lower  part  of  the  cervical  enlargement,  or  it  may  extend 
upward  to  the  pons  or  downward,  or  may  be  limited  to  the 
lumbar  region. 

Symptoms. — These  are  caused  by  the  meningitis,  by  the  com- 
pression of  the  posterior  roots,  and  by  compression  of  the  cord. 
The  distribution  of  the  symptoms  is  dependent  upon  the  extent 
and  location  of  the  exudate.  There  is  usually  pain  in  the  back, 
between  the  shoulders,  in  the  neck,  and  even  in  the  head.  Stiff- 
ness and  tenderness  are  often  present  in  the  cervical  region  or 
in  other  parts  of  the  back.  Severe  neuralgic  pains  following 
the  course  of  the  nerves  that  originate  in  the  affected  region  are 
the  earliest  and  most  prominent  symptoms.  As  the  disease 
advances,  which  it  does  very  slowdy,  there  follow  paralysis  of 
the  atrophic  type  in  the  distribution  of  the  nerves,  disturbances 
of  sensation  in  the  corresponding  area,  and,  if  the  disease  pro- 
gresses further,  to  these  local  symptoms  are  added  the  evidences 
of  spinal  compression,  such  as  spastic  paralysis  of  the  legs, 
disturbances  of  sensation,  bowel  and  bladder  disorders,  etc. 

The  disease  is  further  characterized  by  irregular  exacerbations 
of  symptoms. 

If  the  upper  cervical  region  is  involved,  the  first  symptoms  to 
appear  are  local  pain  and  stiffness,  with  neuralgic  pains  in  the 
distribution  of  the  cervdcal  nerv- es.  If  the  lower  cervical  region 
16  involved,  in  addition  to  the  local  symptoms  pain  will  occur  in 
the  distribution  of  the  ulnar  and  median  nerves.  If  the  exudate 
appears  first  in  the  lumbar  region,  in  addition  to  the  local  symp- 
toms there  will  be  neuralgic  pains  in  the  lower  extremities. 

Diagnosis. — If  the  disease  affects  the  cer\-ical  region  the 
diagnosis  is  not  difficult.  It  must  be  differentiated  from  dis- 
eases of  the  vertebral  bodies  and  from  tumors.  From  disease  of 
the  vertebral  bodies  it  is  differentiated  by  .T-ray  examination, 
by  the  usual  absence  of  tenderness,  by  the  chronic  course,  and 
by  the  intense  neuralgic  pains,  followed  by  atrophic  paralysis 
long  before  the  occurrence  of  symptoms  pointing  to  interference 


344  MANUAL   OF  NERVOUS   DISEASES 

with  conduction  through  the  cord.  From  tumors  of  the  cord  it 
is  differentiated  by  the  presence  of  muscular  rigidity,  intense 
pain,  and  the  paralytic  symptoms  in  the  distribution  of  the 
affected  nerves  before  the  appearance  of  evidence  of  interference 
with  conduction  in  the  spinal  cord. 

Course. — The  course  of  this  disease  is  very  slow;  it  may  last 
for  many  years  and  cease  to  progress  at  any  time. 

The  prognosis  is  fairly  good  if  the  diagnosis  is  made  early. 

Treatment. — ^The  bowels  should  be  kept  freely  open,  and 
elimination  induced  by  abundant  drinking  of  water.  The  gen- 
eral health  should  be  maintained  by  nutritious  food  and  hygienic 
surroundings.  Pain  may  be  relieved  by  pyramidon,  codein,  etc. 
Mercurial  inunctions  and  large  doses  of  potassium  iodid  are 
indicated.  Some  patients  seem  to  do  well  upon  the  salicylates. 
Daily  warm  baths  are  also  advisable.  Counterirritation  to  the 
spine  over  the  suspected  area  by  means  of  the  actual  cautery 
is  useful.  Tincture  of  iodin  or  cantharides  locally  seems  to 
promote  the  absorption  of  the  exudate.  Surgical  intervention 
is  not  usually  possible,  as  there  is  generally  a  close  adherence 
between  the  membrane  and  the  cord,  and  its  removal  would 
result  in  injury  to  the  cord. 

MYELITIS 

Myelitis  is  a  diffuse  or  disseminated  process  of  inflammation 
and  softening  in  the  spinal  cord. 

Etiology. — ^This  disease  is  not  associated  with  any  particular 
age,  although  occurring  most  frequently  in  middle  life.  In  most 
cases  infection  is  the  cause  of  the  disease.  The  inflammation 
of  the  cord  may  be  the  only  evidence  of  infection,  or  a  myelitis 
may  develop  secondary  to  some  infectious  disease,  such  as  in- 
fluenza, measles,  typhoid  fever,  tonsillitis,  erysipelas,  or  pneu- 
monia, or  it  may  also  follow  syphilis,  tuberculosis,  pregnancy, 
meningitis,  injury  or  operation  on  the  cord,  or  the  result  of  the 
direct  extension  of  inflammatory  conditions  in  the  neighbor- 
hood of  the  spinal  cord.  Exposure  to  cold,  overexertion,  and 
injuries,  such  as  falls  and  blows  upon  the  back,  all  predispose  to 
this  condition.     Chronic  intoxications  may  also  be  a  predis- 


MYELITIS  345 

posing  factor  or  may  be  followed  by  myelitis.     Males  are  more 
frequently  affected  than  females. 

Pathology. — The  inflammatory  lesion  may  be  limited  to  one 
or  two  segments,  or  the  lesion  may  be  disseminated,  with  more 
or  less  normal  tissue  intervening.     The  lesion  may  be  diffuse, 
and  show  a  tendency  to  extend  from  one  segment  to  another, 
either  upward  or  downward  or  in  both  directions.     In  other 
cases  the  infection  is  irregular  in  distribution  and  in  its  advance- 
ment.    Occasionally  the  infection  may  remain  localized  to  a 
single  area.     Macroscopically,  the  gross  appearance  of  the  cord 
may  not  be  altered,  although  some  of  the  vessels  may  appear 
injected  and  the  cord  opposite  the  lesions  may  appear  softer 
than  normal.     On  section  the  spinal  cord  is  seen  to  be  of  semi- 
fluid consistence,  all  differentiation  between  the  gray  and  the 
white  matter  being  obhterated.     It  presents  either  a  yellowish 
or  a  reddish  appearance.     In  less  severe  cases  differentiation 
between  gray  and  white  matter  may  still  be  possible,  and  the 
section  may  present  points  of  congestion  and  irregular  areas  of 
yellowish  or   reddish   color.     Microscopically,   there   are   seen 
congestion  of  the  vessels  and  infiltration  of  the  tissue  by  leuko- 
cytes and  small  cells.     The  cells  of  the  cord  and  the  ner\^e- 
fibers  appear  to  be  in  all  stages  of  degeneration.    There  is  a 
proliferation  of  neuroglia  cells,  and  granular  bodies  are  found 
throughout  the  degenerated  tissue.     In  addition  to  these  changes 
in  the  cord  it  is  frequently  possible  to  isolate  various  pathogenic 
organisms,  such  as  streptococcus,  staphylococcus,  pneumococcus, 
etc.     In  some  cases,  as  a  result  of  the  disintegration  and  inflam- 
mation, there  may  be  total  destruction  of  the  spinal  cord — this 
occurs  in  rapidly  fatal  cases.     In  the  milder  cases  the  destruction 
is  less  complete,  and  if  the  inflammation  subsides,  scar  tissue 
replaces  the  nervous  elements  that  have  been  destroyed.     Those 
cells  that  have  not  been  seriously  damaged  may  resume  their 
function,  the   cells   that  have  been    seriously  injured  or   de- 
stroyed are  incapable  of  regeneration.     As  a  consequence  those 
functions  of  the  body  that  depend  for  their  activity  upon  the 
portions  of  the  cord  which  have  been  destroyed  are  perma- 
nently lost.    In  some  cases  of  myelitis  the  presence  of  pathogenic 
organisms  cannot  be  demonstrated;  this  may  be  due  to  the  fact 


346  MANUAL   OF   NERVOUS   DISEASES 

that  the  organisms  that  have  set  up  the  inflammatory  process 
have  subsequently  disappeared,  or  that  the  inflammatory  process 
is  secondary  to  a  toxic  condition  or  to  an  injury.  In  many  cases 
inflammation  of  the  membranes  of  the  cord  comi)licates  the 
picture  of  the  disease. 

Symptoms. — The  disease  usuaUy  comes  on  more  or  less  acutely; 
less  frequently  there  is  a  subacute  onset,  days,  weeks,  or  months 
elapsing  before  all  the  symptoms  are  evident.  In  some  cases 
there  is  a  slight  rise  of  temperature  as  well  as  a  general  feeling 
of  malaise,  a  more  or  less  rapid  pulse,  etc. ;  wdthin  a  few  hours, 
days,  or  weeks  symptoms  appear  that  point  to  direct  involve- 
ment of  the  cord  itself.  The  character,  severity,  and  distri- 
bution of  the  symptoms  depend  upon  the  location  and  extent  of 
area  involved.  In  some  cases  there  is  a  complete  transverse 
myelitis,  in  others  an  incomplete  transverse  myelitis,  and  in  still 
others  a  disseminated  myelitis.  The  symptoms  arising  from 
these  lesions  are  of  two  kinds:  First,  those  due  to  interference 
with  the  functions  of  the  portion  of  the  cord  that  is  affected,  and, 
second,  those  due  to  interference  with  the  transmission  oi 
impulses  upward  and  downward  through  the  affected  area. 

The  first  group  of  symptoms  consist  of  paralysis  with  atrophy, 
reaction  of  degeneration,  loss  of  the  reflexes,  decreased  sensation 
or  anesthesia,  and  vasomotor,  trophic,  and  secretory  disturbances 
in  the  parts  of  the  body  over  which  the  affected  segments  of  the 
cord  preside. 

The  location  and  severity  of  these  symptoms  depend  upon 
the  segment  of  the  cord  invaded  and  the  extent  of  the  involve- 
m^ent. 

The  second  set  of  symptoms  are  due  to  interference  with 
the  transmission  of  stimuli  through  the  affected  area  of  the  cord. 
They  occur  in  parts  of  the  body  below  the  site  of  the  lesion,  and 
consist  of  weakness  or  paralysis;  exaggeration  of  the  tendon- 
reflexes;  increased  muscle  tone,  giving  rise  to  a  spastic  condition; 
contractures  and  spontaneous  spasmodic  movements.  Babin- 
ski's  sign  is  frequently  present.  The  control  of  the  bladder  and 
rectum  is  usually  lost.  Sensibility  may  be  decreased  or  lost — 
usually  all  forms  of  sensation — tactile,  temperature,  pain,  and 
muscle  sense — are  equally  involved. 


MYELITIS  347 

Trophic  Disturbances. — When  pressure  is  continued  over  an 
area  in  which  sensation  is  lost  a  destructive  condition  is  produced 
that  gives  rise  to  bed-sores.  The  latter  may  be  superficial  in 
nature,  but  sometimes  they  penetrate  very  deeply.  They  are 
especially  prone  to  occur  over  fhe  sacrum,  trochanters,  heeh., 
etc.  Vasomotor  disturbances  may  also  occur,  and  there  may  be 
edema,  coldness  and  blueness  of  the  skin,  an  increase  or  decrease 
of  the  secretion  of  sweat,  etc. 

If  a  transverse  myelitis  exists  in  the  cervical  region,  the  first 
set  of  symptoms  occurs  in  the  upper  extremities  and  the  second 
set  involves  the  trunk  and  lower  extremities.  If  a  transverse 
myelitis  exists  in  the  dorsal  region  of  the  cord,  the  upper  ex- 
tremities will  escape,  the  first  set  of  symptoms  occurring  in  the 
distribution  of  the  nerves  of  the  affected  segment,  and  the  second 
set  affecting  the  trunk  below  the  lesion  and  the  lower  extremities. 
If  a  transverse  myelitis  occurs  in  the  lumbar  and  lumbosacral 
region,  the  entire  picture  is  changed,  owing  to  the  fact  that 
practically  all  the  symptoms  are  of  the  first  type.  In  those 
cases  in  which  the  transverse  myelitis  is  not  complete  the  con- 
dition manifests  itself  in  incompleteness  of  the  individual  S3^mp- 
toms.  In  those  cases  of  myelitis  in  which  numerous  iniiam- 
matory  areas  are  present  at  various  sites  in  the  spinal  cord  the 
symptoms  depend  upon  the  location  of  these  foci  and  upon 
their  extent.  In  cases  in  which  there  has  been  a  complete 
transverse  destruction  of  the  spinal  cord  the  disease  picture 
differs  in  so  far  that  there  will  exist  a  complete  flaccid  paralysis 
with  loss  of  all  reflexes  below  the  site  of  the  lesion. 

Diagnosis. — Myelitis  is  to  be  differentiated  from  multiple 
sclerosis,  tumor  of  the  spinal  cord,  compression  of  the  spinal 
cord,  and  vascular  disease  of  the  spinal  cord. 

From  multiple  sclerosis  the  condition  is  readily  differentiated 
by  the  presence,  in  Uhe  former,  of  nystagmus,  speech  disturb- 
ance, intention  tremor,  etc.,  and  the  absense  of  these  symp- 
toms in  myelitis. 

From  tumor  of  the  spmal  cord  myelitis  is  differentiated  by 
the  much  slowxr  onset  and  the  absence  of  fever,  constitutional 
symptoms,  and  of  a  history  of  some  preceding  infection.  From 
compression  of  the  spinal  cord  it  is  differentiated  by  the  history, 


348  MANUAL   OF   NERVOUS   DISEASES 

ic-ray  examination,  and  mode  of  onset.  From  vascular  diseases 
of  the  spinal  cord  it  is  differentiated  by  the  presence  or  previous 
history  of  general  vascular  disease;  by  the  sudden  onset  of  the 
condition,  without  fever,  pain,  or  constitutional  disturbances; 
by  the  fact  that  the  disease  rapidly  attains  its  maximum  and 
then  either  remains  stationary  or  improves,  or  by  the  occurrence 
of  subsequent  attacks. 

Course. — Myelitis  usually  develops  within  a  period  of  from 
a  few  hours  to  several  weeks  or  months.  The  disease  generally 
runs  a  slow  course.  If  the  patient  lives,  a  certain  amount  of 
improvement  may  be  expected. 

Prognosis. — In  mild  cases  the  prognosis  is  fairly  good;  in  the 
severer  cases,  however,  the  prognosis  as  to  total  recovery  is 
absolutely  unfavorable,  and  as  to  life  is  very  grave,  owing  to  the 
fact  that  there  is  great  tendency  for  infection  to  occur  through 
the  bladder,  rectum,  or  through  bed-sores.  Those  cases  that 
are  secondary  to  infectious  diseases  and  occur  in  young,  healthy 
individuals,  and  those  in  which  there  is  but  little  anesthesia 
seem  to  show  the  greatest  tendency  to  recover. 

The  more  acute  and  at  the  same  time  incomplete  the  develop- 
ment of  the  symptoms,  the  more  favorable,  in  general,  is  the 
prognosis.  The  early  appearance  of  rapidly  spreading  bed- 
sores and  of  complete  paralysis  of  the  bladder  and  rectum  is 
usually  an  indication  of  an  unfavorable  outcome. 

Treatment. — First  and  most  important  is  absolute  rest.  The 
patient  should  be  confined  to  bed  and  moved  as  little  as  possible. 
The  greatest  care  should  be  exercised  to  prevent  the  occurrence 
of  bed-sores,  and  the  skin  should  be  carefully  looked  after. 
Proper  attention  should  be  given  to  the  bowel  and  bladder 
functions.  If  the  condition  follows  an  infectious  disease, 
elimination  by  the  intestines,  skin,  and  kidneys  should  be  en- 
couraged. Counterirritation  along  the  spine  is  useful,  care 
being  exercised  not  to  blister  any  of  the  anesthetic  areas.  The 
patient  should  be  turned  carefully  from  side  to  side,  and  pres- 
sure kept  off  all  bony  prominences  by  properly  adjusted  pillows 
or  rings.  The  patient  should  not  be  allowed  to  sit  up  to  empty 
the  bowel  or  bladder.  Internally,  laxatives,  salol,  the  salicylates, 
or  aspirin  may  be  administered.     Urotropin  may  also  be  given, 


HEMATOMYELIA  349 

but  the  effect  of  this  drug  on  the  kidneys  must  be  watched. 
For  the  spasmodic  conditions  and  for  the  cramps  in  the  muscles 
warm  cloths  may  be  applied,  together  with  bromids  internally. 
In  some  cases  quinin  seems  to  do  good.  Care  should  always 
be  exercised  to  avoid  injuring  the  patient  in  the  anesthetic 
areas.  After  the  disease  has  reached  its  height  and  the  patient 
begins  to  improve,  w^arm  baths  and  massage  seem  to  help.  If 
the  patient  is  confined  to  bed,  every  effort  should  be  made  to 
prevent  the  formation  of  bed-sores.  The  bowels  and  bladder 
should  be  carefully  attended  to.  In  those  areas  in  which  there 
is  an  atrophic  flaccid  paralysis,  galvanic  and  faradic  stimulation 
hasten  recovery.  Later,  when  the  patient  begins  to  walk,  over- 
fatigue and  injury  should  be  guarded  against,  and  in  suitable 
cases  braces,  etc.,  should  be  prescribed. 

HEMATOMYELIA 

This  condition  is  due  to  rupture  of  a  vessel  with  extravasation 
of  blood  into  the  cord  substance. 

Etiology. — Injuries,  such  as  follow  severe  blows,  falls,  dis- 
location or  fracture  of  the  vertebra,  or  direct  trauma  to  the  cord 
as  the  result  of  penetrating  w^ounds,  etc.,  are  by  far  the  com- 
monest causes  of  hemorrhage  into  the  cord.  Forced  flexion  of 
the  vertebral  column  forward  is  especially  apt  to  induce  a 
hemorrhage  into  the  cord.  Violent  muscular  exertion,  such  as 
lifting  heavy  weights,  may  be  followed  by  rupture  of  a  vessel. 
In  individuals  of  the  hemorrhagic  diathesis  spontaneous  hemor- 
rhage may  occur,  and  it  may  also  take  place  after  tA^phoid  fever, 
in  the  puerperium,  after  severe  labor,  etc.  Hemorrhage  into 
the  cord  may  likewise  occur  in  areas  which  are  already  diseased, 
as  in  the  presence  of  tumors,  syringomyelia,  myelitis,  etc. 

Pathology. — Spinal  hemorrhage  almost  alw^ays  occurs  in  the 
gray  matter.  When,  however,  it  is  due  to  direct  injury,  such  as 
fracture,  dislocation,  or  penetrating  wounds,  the  hemorrhage 
may  involve  any  portion  of  the  cord  and  may  also  take  place 
into  the  spinal  canal.  The  gray  matter,  being  supplied  by  larger 
vessels,  is  especially  predisposed  to  hemorrhage. 

Any  segment  may  be  affected,  but  the  enlargements,  particu- 


35©  MANUAL   OF   NERVOUS   DISEASES 

larly  the  cervical,  are  more  frequently  involved.  The  hemor- 
rhage may  extend  through  the  whole  central  gray  matter,  or  be 
limited  to  one  side  or  even  to  one  horn.  It  is  seldom  so  extensive 
as  to  give  rise  to  swelling  of  the  cord,  and  it  is  especially  likely  to 
spread  in  the  longitudinal  direction  of  the  cord.  Externally, 
the  cord  may  show  no  evidence  of  the  existence  of  a  hemorrhage. 
Occasionally  the  cord  may  be  ruptured  and  the  hemorrhage 
reach  the  surface  of  the  cord.  In  some  cases  inspection  of  the 
cord  may  reveal  little  or  nothing,  whereas  in  others  marked 
disintegration  of  the  cord  substance  and  hemorrhage  through- 
out the  subdural  space  may  be  seen.  On  section,  if  the  patient 
dies  within  a  short  time,  the  clot  will  be  found  surrounded  by 
broken-down  cord  tissue,  etc.  If  the  patient  survives  for  some 
time,  the  clot  may  be  partially  absorbed,  and  the  tissue  about  it 
be  stained  a  yellowish  red,  the  nervous  elements  appearing  to  be 
in  all  stages  of  disintegration.  In  those  patients  who  survive 
a  secondary  degeneration  develops  in  the  cord  above  and  below 
the  injured  segment. 

Symptoms. — ^The  symptoms  depend  upon  the  location  of  the 
hemorrhage  and,  to  a  certain  extent,  upon  the  cause.  If  the 
hemorrhage  follows  a  dislocation  or  fracture  of  the  vertebral 
bodies,  in  addition  to  the  symptoms  pointing  to  involvement 
of  the  cord  there  occurs  evidence  of  local  injury.  As  a  rule, 
there  is  deformity  and  muscular  rigidity,  with  fixation  of  the 
back.  Movement  causes  pain  at  the  point  of  injury  and  in  the 
distribution  of  the  nerves  which  are  compressed  or  lacerated. 
:r-Ray  examination  will  usually  reveal  the  extent  of  injury  in  so 
far  as  the  bony  structures  are  concerned.  In  some  cases  no 
deformity  is  present  and  the  skiagram  reveals  no  abnormality, 
but  the  clinical  symptoms  nevertheless  point  to  extensive 
involvement  of  the  spinal  cord. 

In  those  cases  in  which  hemorrhage  takes  place  into  diseased 
tissues  of  the  cord  the  symptoms  of  hemorrhage  are  added  to 
those  of  the  preexisting  disease.  When  the  hemorrhage  follows 
a  penetrating  wound,  there  frequently  occurs  a  purulent  in- 
flammation of  the  meninges  as  well  as  of  the  cord  itself.  In 
these  cases,  in  addition  to  the  symptoms  resulting  from  in- 
volvement of  the  cord,  there  are  marked  pain  and  rigidity  of  the 


HEM  ATOMYELIA  3  5 1 

back,  due  to  the  meningitis.  The  symptoms  pointing  to  in- 
volvement of  the  cord  vary  according  to  the  site  of  the  hemor- 
rhage. There  is  usually  a  sudden  interruption  of  conduction 
in  the  spinal  cord.  If  the  patient  is  standing,  he  falls.  Para- 
plegia, loss  of  control  of  the  bowel  and  bladder,  and  sensory 
disturbances  develop  below  the  site  of  the  lesion,  and  vasomotor 
and  trophic  disturbances  soon  appear. 

The  symptoms  increase  in  severity  and  extent  during  the 
first  few  hours.  The  distribution  of  the  symptoms,  of  course, 
depends  upon  the  location  of  the  hemorrhage  within  the  cord:  if 
the  lesion  is  in  the  cervical  enlargement,  there  will  be  a  flaccid 
paralysis  of  the  upper  extremities,  with  vasomotor,  trophic,  and 
secretory  disturbances;  anesthesia  in  the  areas  corresponding  to 
the  segments  that  are  affected ;  disturbances  or  loss  of  the  tendon- 
reflexes,  and  disturbance  of  electric  reaction  of  the  affected 
muscles.  Spastic  paralysis  affects  the  part  of  the  body  below 
the  lesion,  and  there  are  increase  of  deep  reflexes,  decrease  of  the 
superficial  reflex,  bowel  and  bladder  disturbances,  complete  or 
.partial  anesthesia,  the  development  of  bed-sores,  and  vaso- 
motor and  trophic  disturbances.  If  the  lumbar  enlargement  is 
affected,  there  is  flaccid  paralysis  of  the  legs,  with  absence  of  the 
tendon  reflexes,  atrophy  of  the  muscles,  and  complete  or  partial 
anesthesia,  corresponding  to  the  segments  that  are  affected, 
bow^el  and  bladder  disturbances,  etc.  If  the  lesion  is  limited  to 
the  three  lower  sacral  segments,  the  symptoms  consist  of  loss  of 
control  of  the  bowel  and  bladder  functions,  with  complete  re- 
laxation of  the  sphincters,  loss  of  sexual  power,  and  anesthesia 
limited  to  the  perineum,  posterior  part  of  the  scrotum,  or  pos- 
terior half  of  the  labia,  and  extending  in  a  heart-shaped  area 
over  the  sacrum.  In  those  cases  in  which  the  hemorrhage  is 
irregular,  or  in  which  one  side  of  the  cord  is  principally  affected, 
the  symptoms  are  not  symmetric — the  paralysis  and  sensory 
disturbances  vary  in  distribution  and  degree  on  the  two  sides  of 
the  body.  In  cases  in  which  the  lesion  is  limited  to  one-half  of 
the  cord,  Brown- Sequard's  syndrome  occurs;  this  is  character- 
ized by  the  following  combination  of  symptoms:  On  the  side  of 
the  lesion  there  is  spastic  paralysis,  with  increased  tendon- 
reflexes  and  decrease  or  loss  of  muscle  sense  in  the  parts  below 


352  MANUAL   OF   NERVOUS   DISEASES 

the  lesion;  a  narrow  zone  of  anesthesia  about  the  body,  at  the 
level  of  the  lesion,  in  which  all  forms  of  sensation  are  affected. 
On  the  side  opposite  the  lesion  there  is  no  paralysis;  slight 
increase  of  tendon  reflexes;  lossof  the  senseof  touch,  temperature, 
and  pain,  up  to  a  line  about  the  body  somewhat  lower  than  the 
area  of  anesthesia. 

In  most  cases  there  is  pain  in  the  back;  this,  however,  is  not 
severe  or  persistent  unless  the  spinal  meninges  are  involved. 
There  may  also  be  slight  rise  in  temperature  within  the  first  few 
days  or  weeks. 

Course  and  Prognosis. — The  onset  is  usually  sudden.  The 
symptoms  may  become  more  intense  for  several  hours,  and  then 
remain  stationary,  or  the  patient's  general  condition  may  grow 
much  worse.  A  temperature  of  from  ioo°  to  ioi°  F.  usually 
occurs.  Some  cases  develop  extensive  bed-sores  and  gradually 
become  weak,  emaciated,  and  eventually  die.  In  others  after 
a  few  days  the  symptoms  begin  to  subside.  If  death  does  not 
rapidly  ensue  in  those  cases  in  which  the  hemorrhage  is  not 
extensive  and  is  not  due  to  fracture,  dislocation,  penetrating 
wounds,  or  secondary  to  some  diseased  tissue  of  the  cord,  as  a 
rule  improvement  takes  place  within  a  few  days  or  weeks.  The 
symptoms  that  are  the  result  of  compression  gradually  disappear. 
Improvement  goes  on  only  to  a  certain  point,  for  all  the  symptoms 
due  to  destruction  of  the  substance  of  the  cord  are  permanent. 
The  later  danger  in  these  cases  is  from  toxemia,  infection,  etc., 
as  the  result  of  bed-sores,  cystitis,  etc.  The  prognosis  in  those 
cases  secondary  to  injury  of  the  spinal  column  and  penetrating 
wounds,  etc.,  depends  largely  upon  the  degree  and  severity  of 
the  symptoms:  the  higher  the  lesion,  the  more  unfavorable  is 
the  prognosis  both  as  to  life  and  as  to  degree  of  recovery.  Those 
symptoms  that  are  due  to  pressure,  if  not  too  long  continued, 
usually  disappear,  whereas  those  that  are  due  to  destruction  of 
the  cord  tissue  are  permanent. 

Diagnosis. — This  condition  is  differentiated  from  myelitis  by 
the  fact  that  in  myelitis  the  onset  is  never  so  sudden — there  are 
usually  premonitory  symptoms.  From  hemorrhage  into  the 
spinal  meninges  the  disease  is  differentiated  by  the  fact  that 
in  the  former  there  occur  symptoms  of  irritation,  such  as  severe 


MYELOMALACIA  353 

pain  in  the  back,  tenderness  of  the  muscles  to  pressure,  stiffness 
of  the  back,  and  symptoms  of  compression  of  the  roots  and  cord 
which  develop  slowly.  Spinal  puncture  is  also  an  aid  to  diag- 
nosis. From  myelomalacia  the  condition  is  differentiated  by 
the  freedom  from  temperature  on  the  second  or  third  day,  by 
the  history  of  the  absense  of  exciting  causes  of  hemorrhage, 
by  the  presence  of  a  low  blood-pressure,  and  the  evidence  of 
general  vascular  disease.  From  acute  poliomyelitis  it  is  differ- 
entiated by  the  fact  that  this  disease  is  usually  ushered  in  by  a 
feverish  stage,  by  the  absence  of  sensory  disturbance,  and  by 
the  peculiar  distribution  of  the  motor  paralysis. 

Treatment.— Absolute  rest  for  several  weeks.  All  movements 
should,  as  far  as  possible,  be  prevented.  Treat  the  cause. 
The  development  of  bed-sores  should  be  guarded  against.  The 
bowels  and  bladder  should  receive  proper  attention.  The  diet 
should  be  light  and  non-stimulating.  In  those  cases  in  which 
the  occurrence  of  a  meningeal  or  epidural  hemorrhage  is  sus- 
pected, lumbar  puncture  or  operative  interference  is  advisable. 

MYELOMALACIA 

This  condition  is  due  to  occlusion  of  the  arteries  by  thrombi, 
with  subsequent  softening  and  disintegration  of  the  portion  of 
the  spinal  cord  supplied  by  the  aft'ected  vessels. 

Etiology. — ^Among  the  causes  miay  be  mentioned:  Cardiac 
disease;  atheroma  of  the  larger  vessels;  syphilis,  old  age,  states 
of  general  weakness,  malnutrition,  chronic  diarrhea,  infectious 
diseases,  anemia,  the  puerperal  state,  overexertion,  strains,  etc. 

Pathology. — When  accompanied  by  the  transudation  of 
blood-cells  the  area  of  softening  may  be  red ;  when  the  condition 
has  been  one  of  simple  death  of  tissue  it  may  be  white ;  when  the 
process  is  not  observed  until  after  a  fatty  degeneration  has 
ensued  the  area  will  be  yellow.  Microscopic  examination  shows 
cells  and  fibers  in  various  states  of  disintegration;  neuroglia 
cells  and  fibers  in  a  state  of  hyperplasia;  granular  debris;  and 
in  cases  of  red  softening,  the  presence  of  many  red  blood-cells. 

In  the  course  of  time  the  products  of  disintegration  are  ab- 
sorbed, being  replaced  by  connective  tissue,  and  leaving,  in 
23 


354  MANUAL   OF   NERVOUS   DISEASES 

place  of  the  nervous  tissue,  sclerotic  areas  that  are  irregular  in 
outline  and  variable  in  extent.  These  areas  are  frequently 
wedge  shaped,  with  the  base  directed  toward  the  periphery  of 
the  cord. 

Blood-vessels  usually  show  changes  in  their  wall.  Their 
lumen  is  diminished,  either  as  the  result  of  a  true  endarteritis 
or  from  infiltration  of  the  adventitial  coat  or  thickening  of  the 
intima. 

Symptoms. — Symptoms  are  dependent  altogether  upon  the 
location  of  the  lesion.  They  are  preceded  for  some  time  by 
symptoms  pointing  to  general  vascular  disturbance.  Dis- 
turbances due  to  involvement  of  the  cord  come  on  more  or  less 
acutely  within  a  few  hours.  There  is  no  rise  of  temperature, 
and  usually  no  constitutional  disturbances  occur. 

The  symptoms  are  of  two  kinds:  the  first  are  due  to  the 
destruction  of  the  elements  of  the  spinal  cord  at  the  point  of  the 
lesion,  and  consist  of  atrophic  paralysis,  with  reaction  of  de- 
generation in  the  muscles  supplied  by  the  cells  situated  in  the 
anterior  horns,  which  have  been  destroyed;  loss  of  the  reflexes, 
which  takes  place  through  the  affected  segments;  paresthesia 
and  anesthesia  in  the  area  of  skin  connected  with  the  affected 
segment.  The  second  set  of  symptoms  are  produced  by  inter- 
ference with  the  transmission  of  impulses  from  above  and  below 
through  the  affected  area.  They  consist  of  spastic  paralysis  or 
weakness,  with  increased  reflexes  below  the  lesion;  disturbance 
of  control  of  the  bowel  and  bladder;  disturbance  or  loss  of  sensa- 
tion; trophic  disorders,  such  as  the  development  of  bed-sores, 
etc. ;  a  tendency  to  muscular  contraction  and  spasms,  etc.  In 
those  cases  in  which  the  lesion  is  situated  in  the  lumbar  enlarge- 
ment of  the  cord  the  symptoms  are  all  practically  of  the  first 
type.  The  level  of  the  sensory  disturbances  is  the  best  indication 
as  to  the  location  of  the  lesion. 

Diagnosis. — The  disease  is  to  be  differentiated  from  hemor- 
rhage into  the  cord  and  from  myelitis.  From  hemorrhage  into 
the  cord  it  is  distinguished  by  the  absence  of  the  usual  causes  of 
the  hemorrhage  and  the  absence  of  slight  rise  in  temperature; 
the  presence  of  low  blood-pressure;  the  slower  onset,  etc.  From 
myelitis  it  is  not  always  possible  to  differentiate  this  condition. 


SENILE   PARAPLEGIA  355 

Myelomalacia  shows  a  more  acute  onset,  an  absence  of  temper- 
ature, and  is  more  apt  to  occur  after  a  debilitating  or  infectious 
disease  than  during  the  course  of  such  a  disease. 

Course. — The  onset  is  usually  more  or  less  sudden,  the  disease 
attaining  its  height  in  a  few  hours,  and  remaining  at  this  point 
for  several  days,  after  which  gradual  improvement  takes  place 
up  to  a  certain  point,  the  patient  then  entering  a  chronic  state 
similar  to  that  of  chronic  myelitis. 

The  prognosis  depends  upon  the  patient's  general  condition, 
upon  the  extent  of  the  lesion,  and  upon  the  subsequent  care  the 
patient  receives.  The  prognosis  as  to  life  is  usually  fairly  good, 
as  to  improvement  fair,  but  as  to  total  recovery  very  unfavor- 
able. 

Treatment. — The  patient  should  be  kept  in  bed,  great  care 
being  taken  to  avoid  the  development  of  bed-sores.  The 
bowels  and  bladder  should  be  carefully  looked  after.  The 
general  nutrition  of  the  patient  should  be  improved  by  proper 
food,  fresh  air,  massage,  etc.  Internally,  potassium  iodid  in 
small  doses  and  strychnin  in  proper  doses  several  times  a  day 
should  be  given. 

SENILE   PARAPLEGIA 

In  old  age  a  condition  may  occur  that  is  characterized  by  a 
progressive  weakness  in  the  lower  extremities,  with  some  stiff- 
ness, to  which  may  be  added  disturbance  of  sensation  and  weak- 
ness of  bowel  and  bladder  control.  This  condition  is  especially 
apt  to  occur  in  those  who  are  feeble  and  who  have  a  more  or 
less  general  degeneration  of  the  cardiovascular  system. 

The  patients  usually  complain  of  a  sensation  of  numbness  and 
tire  easily.  There  is  difficulty  in  retaining  the  urine.  The 
disease  progresses  slow^ly.  The  patients  experience  difficulty 
in  ascending  steps,  there  is  a  tendency  to  drag  the  feet,  and  an 
uncertainty  in  the  gait.  There  may  be  a  general  tremulous 
state.  Occasionally  the  patients  will  also  complain  of  weakness 
and  numbness  of  the  upper  extremities. 

Pathology. — This  condition  is  probably  due  to  disturbances  of 
circulation  of  the  cord  and  to  sclerotic  changes  in  the  neighbor- 
hood of  the  vessels,  especially  in  the  white  matter. 


356  MANUAL   OF  NERVOUS   DISEASES 

Prognosis.— As  to  improvement,  the  outlook  is  fairly  good, 
as  most  of  these  patients  respond  well  to  treatment. 

Treatment. — Attention  is  to  be  given  to  the  patient's  general 
condition.  Nourishing  food,  general  massage,  cardiac  stimu- 
lants, and  properly  administered  hot  and  cold  douches  to  the 
trunk  and  spme  are  all  useful  in  the  treatment  of  this  condition. 

LANDRY'S   PARALYSIS    (ACUTE   ASCENDING 
PARALYSIS) 

This  disease  is  characterized  by  an  acute  ascending  paralysis, 
beginning  in  the  lower  limbs,  and  rapidly  ascending  to  involve 
the  body,  arms,  and  respiratory  muscles.  It  is  attended  by 
fever  and  constitutional  disturbances,  death  generally  ensuing 
within  a  few  days. 

Etiology. — ^The  disease  is  believed  to  be  caused  by  some  acute 
toxemia  or  infection.  Up  to  the  present  time  there  is  no  consen- 
sus of  opinion  as  to  the  source  or  character  of  the  causative  agent. 

Pathology. — No  definite  pathologic  changes  are  present. 
In  some  cases  a  disseminated  inflammatory  condition  of  the 
central  nervous  system  has  been  described;  in  other  cases  an 
inflammatory  condition  in  the  anterolateral  columns  has  been 
seen;  anterior  horn  inflammation  and  peripheral  nerve  inflam- 
mation have  also  been  described.  The  most  constant  changes 
seem  to  be  inflammatory  and  vascular  in  nature  and  to  involve 
the  gray  matter  of  the  spinal  cord. 

Symptoms. — The  disease  is  characterized  by  a  general  feeling 
of  malaise,  slight  fever,  which  is  accompanied  by  weakness,  and 
then  paralysis,  begininng  in  the  lower  extremities.  This 
paralysis  is  flaccid  in  t}^e,  and  extends  rapidly  to  involve  the 
muscles  of  the  trunk,  next  of  the  arms,  then  of  the  neck,  and 
last  involving  the  muscles  of  deglutition,  of  speech,  and  of  the 
face.  When  the  arms  are  affected,  it  begins  in  the  fingers  and 
gradually  advances  upward.  The  bladder  and  rectum  usually 
remain  normal.  There  is  a  loss  of  the  tendon  reflexes.  As  the 
disease  progresses  marked  respiratory  disturbances  appear  and 
death  usually  supervenes  with  symptoms  of  asphyxia.  This 
occurs  in  some  cases  within  three  days  after  the  onset,  and  in 
others  within  a  week  or  two.    Paresthesias  are  usually  present. 


CONGENITAL    SPINAL   MALFORMATION  357 

There  may  be  other  disturbances  of  sensation,  although  these 
are  not  prominent  as  a  rule.  There  does  not  seem  to  be  any 
decrease  in  the  size  of  the  affected  muscles,  although  this  may 
be  due  to  the  fact  that  death  so  rapidly  follows  the  onset  of  the 
disease  that  atrophic  changes  have  not  had  time  to  manifest 
themselves.  The  electric  reaction  may  or  may  not  be  disturbed. 
The  prognosis  is  very  grave,  as  it  is  extremely  rare  for  a  case 
to  recover. 

CONGENITAL   SPINAL  MALFORMATION    (SPINA 
BIFIDA;  RACHISCHISIS) 

A  congenital  fissure  in  the  spinal  column  is  due  to  an  arrest  of 
development  which  produces  merely  a  defective  closure  of  the 
spinal  column  and  spinal  membranes,  or  the  simultaneous  for- 
mation of  a  tumor,  due  to  a  hernial  protrusion  of  the  menmges 
through  the  fissure  in  the  form  of  a  subcutaneous  swelling 
(meningocele).  The  process  usually  involves  the  cord,  which  it 
also  displaces  outward  (meningomyelocele).  The  absence  of 
the  posterior  wall  of  the  spinal  column  may  be  complete  or 
partial,  only  the  latter  possessing  clinical  interest.  This  in- 
complete closure  is  usually  situated  in  the  lumbosacral  region, 
less  frequently  in  the  cer\dcal  region,  and  very  rarely  in  the  dor- 
sal region.  There  is  no  posterior  closure  of  the  dural  sac  and 
the  meninges  at  the  fissure,  so  that  the  bottom  of  the  sac  is 
occupied  by  a  ventral  portion  of  the  pia  and  arachnoid;  above 
this  is  a  red,  velvety  membrane,  composed  of  a  vascular  plexus 
and  nerv^e  elements;  this  represents  the  more  or  less  distorted 
lower  segments  of  the  spinal  cord  (Fig.  135). 

jMyelomeningocele  is  the  commonest  form  of  spina  bifida.  In 
this  deformity  the  spinal  cord  reaches  its  posterior  wall,  whereas 
the  accumulation  of  fluid  lies  ventral  to  it.  In  most  cases  of 
spina  bifida  the  development  of  the  lower  segments  of  the  spinal 
cord  is  more  or  less  impaired.  The  cord  is  flattened  out  when 
it  enters  the  cyst  formed  by  the  meninges,  or  becomes  attached 
to  the  walls.  These  tmnors  are,  as  a  rule,  situated  in  the  lumbo- 
sacral region  of  the  spinal  column.  They  vary  in  size,  their 
diameter  ranging  from  one  or  two  inches  to  eight  to  ten  inches. 
They  are  elastic  and  fluctuating.     The  defect  of  the  vertebrae 


358 


MANUAL   OF   NEROVUS   DISEASES 


may  be  felt  or  demonstrated  by  radiography.     Spina  bifida  is 
frequently  accompanied  by  other  malformations. 

The  symptoms  arising  from  the  pathologic  changes  in  the 
lumbosacral  cord  and  nerve-roots  are,  to  a  great  extent,  con- 
genital, but  may  not  become  evident  until  later  in  life.  There 
usually  occur  paralysis  of  the  leg  muscles,  atrophy,  reaction  of 
degeneration,  paralysis  of  the  bowels  and  bladder,  disturbance 


Fig.  135. — Spina  bifida  (case  of  Dr.  A.  Shipley). 

or  loss  of  the  knee-jerks,  trophic  disorders,  such  as  perforating 
ulcer,  disturbances  of  sensation,  etc. 

Prognosis.— The  prognosis  is  very  grave.  These  patients 
usually  die  very  early  in  life,  death  being  due  to  ulceration  of  the 
skin  over  the  sac,  to  secondary  infection,  or  to  rupture  of  the 
cyst  with  the  escape  of  cerebrospinal  fluid.  The  more  marked 
the  paralysis,  the  greater  is  the  danger  to  life. 

Treatment  is  purely  surgical.  The  outlook  for  recovery  is 
very  unsatisfactory. 


DISEASES   OF  THE   BRAIN 

PACHYMENINGITIS 

PACHYMENINGITIS   EXTERNA 

Pachymeningitis  externa,  or  inflammation  of  the  external 
surface  of  the  dura  mater,  does  not  occur  as  an  independent 
affection. 

Etiology. — It  develops  in  conjunction  with  affections  of  the 
bones  of  the  skull.  These  may  be  of  traumatic  origin,  or 
secondary  to  caries,  osteomyelitis,  syphilis,  erysipelas,  tumors 
of  the  cranial  bones,  inflammation  spreading  intradurally,  etc. 

The  symptoms  depend  upon  the  cause.  The  symptom  that 
points  toward  involvement  of  the  dura  is  pain,  and  if  the  dura  is 
much  depressed,  there  is  evidence  of  intracranial  pressure. 

The  prognosis  depends  upon  the  cause,  and  the  treatment  is 
surgical. 

PACHYMENINGITIS    INTERNA 

This  is  an  inflammation  of  the  internal  surface  of  the  dura. 

Etiology. — The  condition  affects  especially  the  aged  and 
chronic  alcoholics.  It  occurs  also  in  chronic  inflammatory 
brain  affections  accompanied  by  atrophy  of  the  brain,  in  chronic 
insanity,  tuberculosis;  arteriosclerosis,  and  in  those  suffering 
from  chronic  heart  and  kidney  diseases.  It  may  follow  sun- 
stroke and  the  acute  infectious  diseases,  and  may  complicate 
syphilis,  pernicious  anemia,  leukemia,  hemophilia,  etc.  Trauma 
to  the  skull  is  the  most  frequent  exciting  cause. 

Pathology. — ^A  thin,  vascular,  inflammatory,  membranous  ex- 
udate appears  on  the  inner  surface  of  the  dura,  more  commonly 
over  the  parietal  lobes,  it  may  be  very  extensive.  If  the 
condition  persists  for  some  time  the  membrane  presents  a 
laminated  appearance,  as  if  successive  layers  were  formed  at 
different  times.  This  membrane  is  very  vascular,  the  vessels 
being  extremely  delicate  and  rupturing  easily.     In  rhost  cases 

359 


360  MANUAL   OF   NERVOUS   DISEASES 

hemorrhage  takes  place  into  this  membrane,  with  the  formation 
of  hematomas;  these  are  usually  thin,  but  with  the  successive 
formation  of  layers  pressure  is  produced  against  the  brain, 
which  gives  rise  to  symptoms. 

In  the  course  of  time  this  tissue  becomes  organized  and  may 
undergo  calcareous  degeneration.  Two  theories  as  to  the  cause 
of  the  formation  of  this  exudate  have  been  advanced:  the  first 
is  that  the  exudate  is  inflammatory  in  origin,  and,  the  vessels 
being  very  delicate  and  thin,  rupture  easily,  giving  rise  to  hemor- 
rhage; the  second  holds  that  first  a  hemorrhage  occurs,  which 
later  becomes  organized  and  forms  this  membranous  exudate, 
and  that  subsequent  hemorrhages  are  responsible  for  subsequent 
layers.  When  the  hemorrhage  causes  an  increase  of  symptoms 
the  condition  is  known  as  pachymeningitis  interna  haemor- 
rhagica. 

Symptoms. — The  disease  may  exist  for  years  without  giving 
rise  to  any  marked  symptoms.  In  many  cases  the  symptoms  of 
the  brain  affection  mask  the  manifestations  of  the  pachymen^ 
ingitis,  and  the  true  condition  is  only  discovered  at  autopsy. 
The  symptoms  that  can  be  attributed  directly  to  the  pachymen- 
ingitis are  restlessness,  dull  headache,  difficulty  in  concentrating 
the  thoughts,  mental  slowness,  hemiplegic  or  epileptic  seizures, 
comatose  states  that  may  last  for  long  periods,  evidence  of 
intracranial  pressure,  slow  pulse,  respiratory  disturbances,  and 
choked  disc.  There  may  be  local  tenderness  of  the  skull  to 
percussion,  etc. 

The  course  of  the  disease  is  usually  a  very  slow  one,  and  may 
be  greatly  prolonged  or  may  rapidly  prove  fatal. 

The  condition  is  usually  characterized  by  a  gradual  remission 
of  symptoms,  with  a  period  during  which  the  patient  is  almost 
completely  relieved  of  the  symptoms  pointing  to  involvement  of 
the  dura.  Then  occurs  a  more  or  less  sudden  return  of  the 
symptoms.  These  attacks  are  particularly  apt  to  follow  trauma 
to  the  head,  sudden  exertions,  acute  illness,  etc. 

Prognosis. — The  prognosis  is  dependent  upon  the  cause.  In 
some  cases  death  follows  rapidly  after  an  acute  exacerbation  of 
symptoms,  but  in  most  cases  the  course  is  prolonged,  with  re- 
missions and  exacerbations  of  symptoms- 


MENINGEAL   HEMORRHAGE  361 

Diagnosis. — The  diagnosis  is  rarely  made  during  life.  In 
individuals  suffering  from  chronic  mental  affections,  chronic 
alcoholism,  etc.,  the  existence  of  a  pachymeningitis  haemorrhagica 
may  be  suspected  when  there  are  present  restlessness,  dull  head- 
ache, slowness  of  the  mental  processes,  transient  comatose 
states,  or  epileptiform  seizures. 

In  doubtful  cases,  especially  after  trauma  to  the  head,  lumbar 
or  cranial  puncture  may  enable  one  to  make  a  diagnosis. 

Treatment. — Where  the  condition  is  suspected,  the  patient 
should  be  put  to  bed  and  guarded  against  injury.  Ice-bags 
should  be  applied  to  the  head.  Elimination  by  the  bowels  and 
kidneys  is  to  be  brought  about.  The  diet  should  be  light,  and 
in  plethoric  individuals  bleeding  is  indicated.  Lumbar  puncture 
or,  where  the  evidence  is  sufficient,  opening  of  the  skull  and 
removal  of  the  membrane  and  clot  constitutes  the  surgical 
treatment. 

MENINGEAL  HEMORRHAGE 

Hemorrhage  may  occur  either  between  the  dura  and  the  skull 
or  between  the  dura  and  the  brain,  or  it  may  take  place  beneath 
the  pia.  Extradural  hemorrhage  usually  comes  from  the  meningeal 
arteries,  and  is  generally  the  result  of  injury  to  the  skull.  Intradu- 
ral hemorrhage  may  arise  from  laceration  of  meningeal  arteries,  of 
the  veins  in  the  pia  or  of  veins  opening  into  the  sinuses.  Either 
of  these  forms  of  hemorrhage  may  be  caused  by  trauma  without 
coincident  rupture  of  the  continuity  of  the  bones.  Subarachnoid 
hemorrhages  occur  usually  after  severe  injuries  in  which  the 
brain  substance  is  also  involved:  this  is  the  type  of  hemorrhage 
that  usually  occurs  in  infants  after  prolonged  or  difficult  labor 
(Fig.  136),  and  is  sometimes  seen  in  individuals  who  have  sus- 
tained a  blow  on  the  head  the  force  of  which  was  widely  dif- 
fused. The  site  of  the  hemorrhage  usually  corresponds  to  the 
site  of  the  injury,  but  arterial  laceration  through  contrecoup 
takes  place  on  the  opposite  side  or  on  both  sides. 

The  amount  of  blood  effused  may  reach  200  grams  or  more. 
The  blood  may  form  one  large  clot,  or  may  be  diffused  as  a  thin 
layer  over  the  surface  of  the  brain;  if  it  is  subarachnoid,  it  may 
be  scattered  irregularly  in  thin  layers  beneath  the  arachnoid, 


362 


MANUAL   OF  NERVOUS   DISEASES 


over  the  entire  surface  of  the  brain,  or  be  Hmited  to  several  lobes 
or  convolutions. 

Extradural  Hemorrhage. — Symptoms. — The  symptoms  of 
extradural  hemorrhage  depend  upon  the  location  of  the  hemor- 
rhage. As  a  rule,  there  is  a  history  of  injury,  followed  more  or 
less  quickly  by  the  onset  of  a  comatose  condition,  sometimes 
immediately  and  at  other  times  after  the  expiration  of  several 
hours.  Weakness  or  paralysis  occurs  upon  the  opposite  side 
to  the  injury.  The  pupil  on  the  paralyzed  side  is  contracted, 
whereas  that  on  the  side  of  the  injury  is  dilated. 


Fig.  136. — Subpial  hemorrhage  following  labor. 


If  the  patient  regains  consciousness,  weakness  or  paralysis, 
disorders  of  speech,  disturbance  of  sensation,  etc.,  may  be 
discovered. 

Diagnosis. — ^The  diagnosis  is  made  from  the  history  of  injury 
and  from  the  symptoms.  Lumbar  puncture  in  these  cases  does 
not  show  the  presence  of  blood  in  the  cerebrospinal  fluid,  but 
may  disclose  a  brownish-yellow  staining  of  the  fluid. 

Treatment. — These  cases  should  be  operated  upon  as  soon  as 
the  diagnosis  is  made.  The  lacerated  vessels  should  be  ligated 
and  the  clot  removed. 

Symptoms  of  Intradural  Hemorrhage. — In  these  cases,  either 
with  or  without  fracture  of  the  skull,  there  may  be  a  stuporous 
state  due  directly  to  the  injury.     If  stupor  occurs,  the  patient 


MENINGEAL  HEMORRHAGE  363 

may  regain  full  consciousness,  only  to  lose  it  again  after  a  certain 
time.  After  several  hours  restlessness  may  develop,  or  there 
may  be  delirious  excitement,  which  soon  passes  into  a  state  of 
stupor  that  may  deepen  into  coma.  There  is  evidence  of  intra- 
cranial pressure,  the  pulse  becoming  slow,  and  the  breathing 
irregular  and  stertorous.  Choked  disk  sometimes  develops. 
There  are  usually  at  first  unilateral  spasms,  followed  later  on 
by  paralytic  symptoms.  There  is  generally  a  rise  in  tempera- 
ture, and  the  pupil  on  the  affected  side  may  be  dilated.  Local- 
ized tenderness  of  the  skull  may  be  present.  In  some  cases  the 
symptoms  are  more  indistinct  and  vague,  the  patient  complain- 
ing of  a  transient  giddiness,  pain  in  the  head,  loss  of  memory, 
and  mental  slowness. 

The  symptoms  of  subaraehnoid  hemorrhage  are  quite  similar 
to  those  just  enumerated.  In  this  latter  group  of  cases  the 
symptoms  gradually  progress  and  increase  for  hours  or  even 
days,  and  then  subside  very  slowly  and  only  partially  disappear. 
There  is  a  gradual  loss  of  consciousness,  and  headache,  slow 
pulse,  vomiting,  respiratory  disturbances,  and  rise  of  temperature 
occur.  To  these  symptoms  are  added  others  pointing  toward 
interference  of  function  of  the  portion  or  portions  of  the  brain 
that  are  aiEfected,  such  as  paralysis,  loss  of  sensation,  aphasia, 
hemianopsia,  etc. 

Course. — Following  an  injury,  strain,  or  compression  the 
patient  may  become  unconscious.  He  may  remain  in  this  state 
or  may  regain  consciousness,  or  within  a  few  hours  or  days  after 
the  onset  of  the  affection  there  may  be  a  gradual  loss  of  con- 
sciousness or  a  stuporous  state  may  develop.  In  some  cases 
a  progression  of  symptoms  develops,  pointing  to  involvement 
of  successive  areas  of  the  brain.  These  are  at  first  irritative 
and  later  paralytic.  In  some  cases  the  symptoms  are  accompa- 
nied by  a  delirious  state,  slow  or  rapid  pulse,  disturbance  of  the 
respiratory  rate,  rise  of  temperature,  etc.  The  coma  may  deepen, 
the  pulse  become  rapid  and  irregular,  and  death  ensue.  In 
other  cases  the  patient  may  regain  consciousness  and  gradual 
improvement  in  the  symptoms  appear  for  a  time,  and  then  the 
condition  may  remain  stationary. 

Prognosis. — The   prognosis   depends   upon   the   extent   and 


364  MANUAL   OF   NERVOUS   DISEASES 

location  of  the  hemorrhage.  As  to  life  it  is  usually  good,  except 
in  cases  of  very  extensive  hemorrhage.  The  prognosis  as  to 
recovery  of  function  depends  upon  the  amount  of  brain  tissue 
that  has  been  destroyed. 

Treatment — In  those  cases  in  which  the  symptoms  point  to  a 
localized  collection  of  blood,  trephining  the  skull  over  the  affected 
area,  with  ligation  of  the  lacerated  vessels,  is  to  be  done  as  soon 
as  possible.  When  the  symptoms  point  to  diffuse  extravasation 
of  blood,  the  patient  should  be  put  to  bed,  the  head  slightly 
elevated,  and  ice-caps  applied  to  the  head.  Internally,  calomel, 
followed  by  a  saline  purgative,  is  to  be  administered.  The 
bladder  should  be  emptied  at  regular  intervals.  The  diet  should 
be  very  light.  If  there  is  evidence  of  increased  intracranial 
pressure,  a  decompression  operation  is  indicated. 

MENINGITIS 

This  is  an  inflammatory  condition  of  the  pia-arachnoid, 
usually  affecting  also  the  brain,  especially  the  cortex,  so  that 
in  most  cases  a  meningo-encephalitis  is  present.  The  onset 
is  generally  acute,  and  there  is,  as  a  rule,  a  diffuse  distribution, 
although  in  some  varieties  the  inflammation  begins  in  a  limited 
area  and  extends  gradually. 

Etiology. — Inflammation  of  the  meninges  is  usually  due  to 
the  presence  of  a  microorganism.  A  purulent  meningitis  may 
be  due  to  streptococci  or  to  staphylococci,  pneumococci,  etc. 
A  special  form  of  meningitis,  known  as  epidemic  cerebrospinal 
meningitis,  or  spotted  fever,  is  caused  by  the  Diplococcus 
intacellularis  of  Weichselbaum. 

Microorganisms  may  reach  the  meninges  from  a  neighboring 
area  of  suppuration,  or  they  may  come  by  way  of  the  blood,  or 
lymph-stream  as  a  part  of  a  general  infection,  or  following  inju- 
ries to  the  skull  with  open  wounds.  The  inflammation  may  be 
due  to  injuries  and  infections  of  the  vertebral  canal  caused  by 
the  entrance  of  infecting  organisms,  with  subsequent  ex- 
tension to  the  cerebral  membranes;  following  erysipelas  or 
purulent  otitis  with  caries  of  the  bone;  extension  of  the  inflam- 
mation from  the  nasal  cavities,  orbit,  or  pharynx;  following 


SEPTIC    OR    SECONDARY   MENINGITIS  365 

acute  infectious  diseases  or  eruptive  fevers,  such  as  typhoid, 
influenza,  etc.  Other  types  may  occur  secondary  to  tuber- 
culosis, syphilis,  chronic  toxemia,  etc.  Basing  the  classification 
on  the  etiology,  at  least  five  varieties  of  meningeal  inflammation 
may  be  said  to  occur: 

1.  Septicemic  or  secondary  meningitis. 

2.  Epidemic  cerebrospinal  meningitis. 

3.  Tubercular  meningitis. 

4.  Syphilitic  meningitis. 

5.  Serous  or  toxic  meningitis  (wet  brain). 

SEPTIC    OR    SECONDARY    MENINGITIS 

This  form  of  meningitis  is  always  secondary  to  some  primary 
cause ;  as  a  consequence,  before  the  manifestations  of  meningitis 
appear  symptoms  pointing  to  the  causative  agent  will  have 
occurred. 

Etiology. — ^Among  the  commonest  forerunners  of  this  form 
of  meningitis  are  diseases  of  the  middle  ear,  the  nose  and  its 
accessory  sinuses,  injury  to  the  skull,  operations  upon  the  head, 
erysipelas  of  the  face,  abscesses  about  the  head  and  face,  septic 
endocarditis,  and  osteomyelitis.  In  addition  to  these  causes 
must  be  mentioned  the  acute  infectious  diseases,  septicemia, 
and  prolonged  gastro-intestinal  or  pulmonary  diseases  in  very 
young  children.  Following  any  of  these  conditions  pathogenic 
organisms  may  gain  access  to  the  cerebral  membranes  and  set 
up  an  inflammatory  condition. 

Pathology. — There  is  first  a  hyperemia  of  the  pia  mater,  which 
later  becomes  cloudy  in  appearance.  The  cerebrospinal  fluid 
is  at  first  turbid,  but  later  becomes  purulent.  Pus  is  found  at 
first  over  the  sulci  of  the  brain,  and  later  the  entire  surface  is 
more  or  less  covered.  The  superficial  tissues  of  the  cortex 
undergo  inflammatory  changes  and  small  hemorrhages  occur. 
The  ventricles  become  somewhat  dilated  and  contain  a  sero- 
purulent  exudate.  In  some  cases,  especially  those  secondary  to 
middle-ear  or  nasal  diseases,  inflammation  may  be  limited  at 
first  to  a  portion  of  the  brain,  finally  spreading.  As  a  general 
rule  the  membranes  of  the  spinal  cord  become  involved. 


366  MANUAL   OF  NERVOUS   DISEASES 

Symptoms. — If  a  meningitis  develops  during  the  course  of 
any  of  the  aforenamed  conditions,  there  is  usually  a  more  or  less 
sudden  exacerbation  of  the  general  constitutional  symptoms 
which  are  present  as  the  result  of  the  causative  affection;  thus 
chills  may  occur,  and  there  is  usually  a  rise  in  temperature;  the 
pulse  becomes  more  rapid,  and  restlessness  develops;  to  these 
symptoms  are  added  evidences  of  involvement  of  the  meninges 
and  brain.  Severe  headache  occurs,  giving  rise  to  great  restless- 
ness, and  in  young  children  there  is  more  or  less  constant  rolling 
of  the  head  from  side  to  side.  In  some  cases  this  last  is  so  con- 
stant as  to  cause  the  rubbing  off  of  the  hair  from  the  back  of  the 
head.  The  patient  becomes  very  irritable,  and  sleep  is  usually 
disturbed,  and  in  some  cases  almost  impossible.  Infants  and 
young  children  frequently  awake  from  a  light  sleep  with  a 
scream  (the  cephalic  cry);  later,  if  the  disease  progresses, 
delirium  alternates  with  stupor,  finally  merging  into  coma. 
There  is  a  general  state  of  hyperesthesia,  evidenced  by  avoidance 
of  bright  light  and  loud  noises,  and  cutaneous  sensitiveness 
appears.  Muscular  twitchings,  cervical  rigidity,  opisthotonos, 
and  convulsions  sooner  or  later  make  their  appearance.  Added 
to  these  symptoms  are  the  manifestation  of  involvement  of  the 
cranial  nerves,  optic  neuritis,  nystagmus,  unequal  pupils,  loss  of 
the  pupillary  reflex,  grinding  of  the  teeth,  facial  paralysis, 
etc.  The  tendon-reflexes  are  usually  increased,  and  there  is 
disturbance  of  control  of  the  rectal  and  vesical  sphincters. 

The  clinical  picture  of  the  case  depends  largely  upon  the 
cause  and  upon  the  portion  of  the  meninges  first  affected.  In 
those  cases  secondary  to  injuries  to  the  skull  the  portions  of 
the  meninges  that  are  first  affected  are  those  closely  related  to 
the  site  of  injury,  and  the  symptoms  that  occur  are  those  due 
first  to  irritation  of  that  portion  of  the  brain,  and  later,  as  the 
affection  extends,  to  the  irritation  of  other  portions.  Those 
cases  that  are  secondary  to  nasal  sinus  disease  and  to  middle-ear 
disease  usually  begin  with  symptoms  pointing  toward  involve- 
ment of  the  adjacent  cerebral  tissues.  In  the  septic  cases,  in 
which  the  organism  generally  gains  access  by  the  blood-stream, 
the  convexity  of  the  brain  is  generally  first  involved,  and  as  the 
inflammation  becomes  more  or  less  diffuse  there  occur  severe 


SEPTIC    OR   SECONDARY   MENINGITIS  367 

headache,  marked  delirium,  great  restlessness,  hypersensitive- 
ness,  and  often  convulsions.  There  is  marked  disturbance  of 
the  mental  state,  manifesting  itself  in  a  loss  of  interest  in  the 
surroundings,  difficulty  in  comprehension,  and  intellectual  slow- 
ness. These  are  followed  by  symptoms  pointing  to  involve- 
ment of  the  base  of  the  brain,  such  as  cervical  rigidity,  cranial 
nervT  involvement,  etc.  This  is  particularly  true  of  those  cases 
which  occur  either  during  the  course  of  or  follow  the  acute 
infectious  diseases,  such  as  influenza,  typhoid  fever,  the  erup- 
tive diseases,  etc. 

When  meningitis  occurs  secondarily  in  very  young  children, 
who  seem  to  be  especially  susceptible,  before  the  close  of  the 
cranial  sutures,  hydrocephalus  develops  if  the  disease  lasts 
more  than  ten  days.  In  addition  to  the  general  constitutional 
disturbances  and  symptoms  pointing  to  involvement  of  the 
meninges,  there  is  usually  a  rapid  emaciation. 

The  blood  count  shows  leukocytosis,  from  12,000  to  30,000 
leukocytes  being  present.  Examination  of  the  urine  frequently 
reveals  the  presence  of  albumin,  sometimes  of  sugar,  and  rarely 
of  casts.  Spinal  puncture  yields  a  fluid  that  is  turbid,  contain- 
ing cells,  leukocytes,  and  microorganisms;  it  generally  flows  under 
increased  pressure. 

Course. — In  some  cases  all  the  symptoms  appear  with  great 
rapidity,  the  disease  running  its  full  course  in  a  few  days.  In 
other  cases  the  symptoms  are  of  slower  onset,  the  irritative 
disturbances  being  the  first  to  appear,  to  be  followed  later  by 
the  paralytic  symptoms:  in  these  cases  the  disease  may  run  a 
slower  course,  lasting  several  weeks. 

The  prognosis  in  this  condition  is  very  serious:  few  recoveries 
take  place,  and  symptoms  pointing  to  brain  destruction,  such 
as  mental  weakness,  paralysis,  blindness,  etc.,  frequently  remain 
as  sequelae. 

Diagnosis. — ^The  diagnosis  is  made  from  the  historv'  of  the 
preceding  illness,  together  with  the  symptoms  of  meningeal 
inflammation.  Spinal  puncture  should  be  made,  and  if  examina- 
tion of  the  fluid  reveals  the  presence  of  pathogenic  organisms 
or  of  abnormal  cellular  constituents  the  diagnosis  is  confirmed. 
Meningitis  must  be  differentiated  from  the  acute  infectious 


368  MANUAL   OF  NERVOUS   DISEASES 

diseases,  especially  pneumonia  and  typhoid  fever,  particularly 
in  the  case  of  children,  in  whom  these  diseases  may  begin  with 
headache,  delirium  or  stupor,  vomiting,  general  hyperesthesia, 
convulsions,  etc. 

A  careful  physical  examination,  spinal  puncture,  and  a  regular 
pulse-rate,  despite  the  increase  in  temperature,  will  usually  clear 
up  the  diagnosis. 

Acute  otitis  media,  especially  in  children,  may  be  accompanied 
by  cerebral  symptoms  that  suggest  a  meningitis.  A  careful 
examination  of  the  cerebrospinal  fluid  will  reveal  the  presence 
or  absence  of  pathogenic  organisms,  abnormal  cells,  or  both. 

Treatment. — ^This  consists,  first,  of  the  proper  treatment  of 
the  underlying  cause,  so  that  the  occurrence  of  meningitis  may 
be  avoided.  In  those  cases  in  which  meningitis  already  exists, 
the  focus  of  infection  should  receive  attention.  The  patient 
should  be  kept  in  a  well-ventilated,  darkened,  quiet  room  and 
ice-caps  be  applied  to  the  head.  The  bowels  should  be  kept 
well  open.  The  pain  is  to  be  controlled  by  codein  and  morphin 
in  proper  doses,  and  the  restlessness  and  convulsions  -diminished 
by  the  adminstration  of  bromids.  Temperature  should  be 
kept  down  as  far  as  possible  by  sponging  with  cool  water.  In 
those  cases  that  require  stimulation,  caffein,  alcohol,  and 
strychnin  are  to  be  used.  The  withdrawal  of  cerebrospinal 
fluid  by  lumbar  puncture  at  times  seems  to  afford  the  patient 
some  relief.  Urotropin  in  proper  doses  has  been  recommended, 
but  seems  to  be  of  little  value. 

EPIDEMIC   CEREBROSPINAL   MENINGITIS 

This  is  an  infectious,  but  not  a  contagious,  disease.  It  is  due 
to  the  Diplococcus  intracellularis  of  Weichselbaum.  The  dis- 
ease usually  occurs  in  epidemics  during  the  winter  and  spring, 
but  sporadic  cases  may  occur  at  any  time.  Children  and  young 
persons  are  most  commonly  affected.  Injuries  may  act  as  the 
exciting  cause,  but  the  organism  is  generally  introduced  by 
way  of  the  lymphatics  from  the  nose  and  pharynx.  Persons 
living  in  crowded  districts  and  amid  unhygienic  surroundings 
are  more  likely  to  be  attacked  than  those  who  live  amid  better 
conditions. 


EPIDEMIC    CEREBROSPINAL   MENINGITIS  369 

Pathology. — Early  in  the  disease  hyperemia  and  congestion 
of  the  pia  mater  occur,  followed  by  a  serofibrinous  exudate 
which  later  becomes  purulent.  These  pathologic  changes  affect 
the  convexity  and  base  of  the  brain,  the  surface  of  the  cere- 
bellum, and  the  spinal  meninges.  The  cerebral  ventricles  con- 
tain a  turbid  and  purulent  fluid.  The  cortex  of  the  brain  also 
becomes  affected,  the  vessels  becoming  dilated.  The  super- 
ficial tissues  are  congested,  and  slight  hemorrhages  and  small 
collections  of  pus  are  found  throughout  the  superficial  layers. 
The  cerebral  nerves  are  embedded  in  and  infiltrated  by  the 
exudate.  The  inflammatory  process  may  extend  along '  the 
auditory  nerves  to  the  internal  ear,  and  set  up  a  purulent 
inflammation. 

Symptoms. — The  symptoms  usually  appear  suddenly.  Chill 
may  or  may  not  occur,  and  there  is  a  rise  of  temperature,  which 
varies  from  101°  to  105°  F.  The  patient  complains  of  a  feeling 
of  illness,  restlessness,  headache,  and  backache;  the  pulse  is 
rapid  and  full,  and  within  a  few  hours  or  days  vomiting  may 
occur.  The  headache  becomes  severe,  and  vertigo  occurs. 
The  patient  appears  to  be  very  ill,  is  restless,  becomes  sensitive 
to  light  and  sound,  unable  to  sleep,  and  complains  of  general 
cutaneous  sensitiveness.  Convulsions  may  occur,  especially 
in  early  childhood.  Within  a  short  time  the  neck  becomes 
stiff,  and  if  the  disease  advances,  the  head  is  retracted  and  a 
state  of  opisthotonos  develops.  Spasms  of  the  muscles  of  the 
extremities  and  face  may  occur,  and  the  pupils  may  be  dilated, 
unequal,  and  not  react  to  light.  Grinding  of  the  teeth,  strabis- 
mus, facial  paralysis,  etc.,  may  also  be  present.  Fever  persists, 
the  temperature  often  rising  to  104°  or  105°  F.,  and  the  patient 
becomes  actively  delirious.  The  abdomen  is  retracted,  the 
bowels  are  constipated,  and  there  is  retention,  with  later  in- 
continence, of  urine.  The  delirium  alternates  with  stupor  and 
coma,  and  is  worse  at  night  and  when  the  temperature  rises. 
About  the  third  day,  in  the  majority  of  cases,  an  eruption 
appears.  This  is  diffused  more  or  less  over  the  entire  body,  and 
may  be  erythematous,  urticarial,  petechial,  or  purpuric.  Herpes 
occurs  early,  the  vesicles  forming  chiefly  upon  the  lips,  the  face, 
the  ears,  and  the  extremities.  The  vesicles  last  only  a  few  days 
24 


370  MANUAL   OF   NERVOUS   DISEASES 

and  then  dry  up.  Irritation  of  the  skin  leaves  dark-red  spots — 
the  tache  cerebrale  of  Trousseau.  Contractures  develop  early, 
and  later  on  paralysis  occurs.  In  those  cases  that  do  not  respond 
to  treatment  there  is  rapid  emaciation.  The  cranial  nerves  are 
almost  always  affected,  and  optic  neuritis,  oculomotor  paralysis, 
deafness,  facial  paralysis,  difficulty  in  swallowing  and  in  articula- 
tion are  prone  to  occur.  The  fever  runs  a  very  irregular  course, 
and  great  variations  in  temperature  are  possible.  The  pulse 
is  usually  rapid  and  irregular,  and  may  vary  at  times  from  40  to 
120  or  even  140  beats  a  minute.  The  respiration  may  also  be 
irregular  in  rate  and  in  type.  At  first  the  patient  is  restless 
and  actively  delirious,  but  later  in  the  disease  he  either  becomes 
comatose  or  assumes  a  state  of  indifference. 

There  is  usually  a  marked  leukocytosis,  the  white-cell  count 
ranging  from  10,000  to  30,000.  The  urine  generally  contains 
albumin  and  casts.  Examination  of  the  cerebrospinal  fluid 
reveals  the  presence  of  an  intracellular  diplococcus.  The 
cerebrospinal  fluid  may  be  clear  at  the  first  puncture,  and  be 
turbid  upon  subsequent  punctures. 

Course. — ^The  course  of  this  disease  varies  in  different  epi- 
demics and  in  different  individuals.  Some  cases  run  a  very 
rapid  course.  In  these  there  are  active  delirium,  convulsions, 
great  prostration,  paralysis,  coma,  and  death  within  a  few  days. 
In  other  cases  in  which  the  .symptoms  are  not  so  severe  there 
may  be  a  remission  in  five  or  six  days,  during  which  the  patient 
seems  very  much  better,  but  which  is  followed  shortly  by  a 
recrudescence  of  all  the  symptoms,  which  may  be  more  severe 
and  result  in  a  fatal  termination  within  a  few  weeks. 

In  those  cases  in  which  a  correct  diagnosis  has  been  made  and 
the  proper  treatment  instituted  there  is  usually  a  marked 
improvement  after  one  or  two  injections  of  Flexner's  antimenin- 
gococcic serum.  In  some  cases,  even  with  this  treatment,  there 
is  a  persistence  of  mental  inertness,  general  hyperesthesia, 
cervical  rigidity,  headache,  etc.  In  such  cases  there  is  usually 
an  obstruction  in  the  communications  between  the  ventricles 
and  the  general  subarachnoid  space. 

Prognosis. — Since  the  discovery  of  Flexner's  serum  the  prog- 
nosis is  fairly  good,  provided  the  diagnosis  is  made  early.    The 


EPIDEMIC   CEREBROSPINAL   MENINGITIS  37 1 

prognosis  is  also  governed  by  the  severity  of  the  case.  In  spite 
of  proper  treatment  some  cases  succumb  rapidly  to  the  disease. 
In  others  recovery  is  incomplete,  certain  symptoms,  such  as 
deafness,  paralysis,  blindness,  headache,  etc.,  becoming  more 
or  less  permanent. 

Diagnosis.— The  condition  is  to  be  differentiated  from  other 
forms  of  meningitis,  typhoid  fever,  uremia,  etc.  The  presence 
of  herpes,  the  history  of  the  case,  and  the  fact  that  spinal  puncture 
yields  a  fluid  containing  an  intracellular  diplococcus  will  readily 
enable  one  to  make  a  correst  diagnosis. 

Treatment. — The  patient  should  be  kept  in  a  cool,  quiet, 
darkened  room,  and  ice-bags  should  be  applied  to  the  head  and 
spine.  The  bowels  must  be  kept  freely  open.  If  the  temper- 
ature rises  above  102.5°  F.,  the  body  should  be  sponged  with 
cool  or  cold  water  every  two  or  three  hours.  In  those  cases  in 
w^hich  there  are  convulsions,  restlessness,  etc.,  the  bromids 
or  opium  in  proper  doses  frequently  repeated  are  of  use.  The 
patient's  strength  is  to  be  supported  by  light,  nourishing  food. 
Water  should  be  given  freely. 

As  soon  as  the  diagnosis  has  been  confirmed  by  w^ithdrawing 
from  15  to  30  c.c.  of  cerebrospinal  fluid,  from  15  to  30  c.c.  of 
Flexner's  antimeningococcic  serum  is  to  be  injected  intraspi- 
nally,  the  larger  doses  being  given  in  the  more  severe  cases. 
The  cerebrospinal  fluid  should  be  examined  daily.  The  dip- 
lococci  disappear  as  the  case  improves,  and  a  leukocyte  count 
should  be  made- daily,  as  there  is  a  gradual  decrease  in  the 
leukocytosis  if  the  case  responds  to  treatment. 

Injections  should  be  given  daily  until  the  diplococcus  dis- 
appears from  the  fluid.  If  there  is  a  recurrence  of  the  symptoms, 
injections  must  again  be  made.  In  some  cases  in  which  there 
is  a  persistence  of  the  cerebral  symptoms,  such  as  coma, 
headache,  etc.,  it  may  be  necessary  to  make  a  ventricular 
puncture,  and  if  the  fluid  thus  withdrawn  contains  diplococci, 
to  inject  the  antimeningococcic  serum  directly  into  the  ventricle. 
After  the  acute  symptoms  have  subsided  the  patient  should 
receive  a  nourishing  diet,  tonics,  and  an  abundance  of  fresh 
air. 


372  MANUAL   OF   NERVOUS  DISEASES 

TUBERCULAR   MENINGITIS 

This  disease  is  due  to  the  invasion  of  the  cerebral  membranes 
by  tubercle  bacilli:  it  is  always  secondary  to  tuberculosis  in 
some  other  portion  of  the  body,  most  frequently  in  the  lungs, 
lymphatic  glands,  bones,  etc. 

Etiology. — ^This  disease  occurs  more  frequently  in  early  life, 
particularly  between  the  second  and  the  fifteenth  year.  It  is 
seen  only  rarely  in  infancy  and  after  the  fortieth  year.  Among 
the  predisposing  causes  are  trauma,  the  acute  infectious  dis- 
eases,— such  as  measles, — whooping-cough,  alcoholism,  catarrhal 
disease  of  the  intestines,  overexertion,  etc. 

Pathology. — ^The  route  by  w^hich  the  tubercle  bacilli  reach 
the  cerebral  membranes  is  not  certainly  known:  they  may  be 
carried  to  the  brain  by  the  blood-stream  and  through  the 
lymphatic  system.  Miliary  tubercles  are  deposited  on  and  in 
the  cerebral  membranes,  there  is  a  serofibrinous  and  gelatinous 
exudate,  and  rarely  pus  is  present.  The  exudate  and  the 
tubercles  are  deposited  in  larger  or  smaller  masses  at  the  base 
of  the  brain,  about  the  anterior  and  posterior  perforated  spaces, 
and  from  here  they  extend  into  the  fissures  and  up  over  the  sur- 
face of  the  brain,  in  some  cases  going  backward  to  the  under 
surface  of  the  medulla,  pons,  and  cerebellum,  and  in  others 
extending  to  the  spinal  membranes.  When  the  process  involves 
the  convexity  of  the  brain,  it  is  more  extensive  in  the  fissures 
and  around  the  blood-vessels.  Miliary  tubercles  occur  not 
only  in  the  exudate,  but  also  in  parts  that  are  free  from  inflam- 
mation. They  present  a  gray  white,  shiny,  nodular  appearance, 
and  vary  in  size  fromi  almost  a  pin-point  to  large  masses  the 
result  of  coalescence  of  smaller  areas.  The  ventricles  are  usually 
distended  and  filled  with  a  serum  in  which  fibrin  and  blood  are 
found. 

The  choroidal  plexuses  are  also  generally  studded  with  tuber- 
cles, and  a  degree  of  hydrocephalus,  depending  upon  the  amount 
of  interference  with  the  circulation  from  the  ventricles  to  the 
general  subarachnoid  space,  and  upon  the  extent  of  ossification 
of  the  cranial  sutures,  is  present.  The  exudation  also  surrounds 
the  nerves,  giving  rise  to  a  neuritis.     As  a  rule,  the  cerebral 


TUBERCULAR  MENINGITIS  373 

substance  itself  is  affected,  resulting  in  diffuse  or  localized 
encephalitis,  which  is  frequently  of  a  hemorrhagic  nature. 
Areas  of  softening  in  the  substance  of  the  brain  and  the  basal 
ganglion  are  frequently  present,  and  may  be  traced  to  obliteration 
of  small  vessels  as  the  result  of  a  tubercular  arteritis. 

Symptoms. — Before  the  symptoms  pointing  to  the  true 
nature  of  the  disease  occur  there  is  usually  a  period,  lasting  for 
some  days  or  even  longer,  during  which  manifestations  pointing 
to  general  disturbance  appear. 

Prodromal  Symptoms. — In  a  child  that  has  previously  been 
healthy,  but  pale  or  poorly  nourished,  or  in  adults  who  have  had 
or  have  been  exposed  to  tuberculosis,  there  occurs  a  period 
during  which  the  individual  is  irritable,  manifests  no  interest 
in  his  surroundings,  is  indifferent,  and  perhaps  at  times  confused. 
The  sleep  is  more  or  less  disturbed  and  interrupted  by  disagree- 
able dreams,  and  there  are  more  or  less  persistent  headache, 
diffuse  pain,  and  sensitiveness,  the  patient  reacting  abnormally 
to  mild  forms  of  irritation.  There  may  be  loss  of  appetite, 
constipation,  loss  of  weight,  and  sometimes  vomiting.  After 
a  shorter  or  longer  period  the  second  stage,  or  stage  of  irritation, 
sets  in. 

Stage  of  Irritation. — ^At  this  time  the  headaches  become  more 
severe,  delirium  develops,  and  convulsions  may  occur.  Rest- 
lessness and  grinding  of  the  teeth  develop,  the  patient  sleeps 
lightly  and  wakes  with  a  scream,  the  head  becomes  retracted, 
there  is  great  sensitiveness  to  light  and  sound,  and  the  h^ad  is 
rolled  from  side  to  side.  No  control  is  exercised  over  the  rectal 
and  vesical  sphincters,  and  there  may  be  tonic  contractures  of 
some  or  of  all  the  muscles  of  the  body,  muscular  twitchings,  etc. 
The  cranial  nerves  are  usually  affected.  The  pupils  are  ir- 
regular, and  strabismus,  nystagmus,  vertigo,  facial  paralysis, 
etc.,  occur.  Throughout  this  stage,  which  may  last  from  a  few 
days  to  two  weeks,  there  is  constant  evidence  of  the  irritative 
condition  of  the  meninges  and  cortex.  The  temperature  in  these 
cases  varies  from  subnormal  or  slightly  above  normal  to  105° 
or  106°  F.  The  pulse  and  respiration  are  irregular,  and  do  not 
usually  correspond  with  the  temperature.  Emaciation  is  rapid, 
and  in  very  young  children  a  hydrocephalus  commonly  develops, 


374  MANUAL   OF  NERVOUS   DISEASES 

in  which  the  increase  in  size  and  shape  of  the  head  is  accompanied 
by  a  slight  bulging  of  the  eyeballs.  During  this  stage  the 
patient  gradually  grows  weaker,  and  the  active  delirium  is 
replaced  by  a  state  of  stupor.  The  skin  is  dry,  and  tache 
cerebrale  is  well  marked;  usually  choked  disk  is  present.  Early 
in  this  stage,  in  spite  of  the  severity  of  the  symptoms,  there 
may  be  remissions,  during  which  the  patient  seems  to  be  better, 
but  as  the  last  stage  approaches  these  intervals  become  less 
frequent  and  are  of  shorter  duration. 

Toward  the  end  of  this  stage  the  stupor  deepens  into  coma, 
the  irritative  symptoms  subside,  and  are  replaced  by  those  of  a 
paralytic  nature. 

The  third,  or  paralytic,  stage  is  characterized  by  the  presence 
of  coma  and  of  paralysis  of  some  of  the  cranial  nerves  and  of 
the  extremities.  The  opisthotonos  is  marked;  the  abdomen  is 
retracted;  the  pupils  are  dilated  and  fail  to  react  to  light;  fever 
is  more  or  less  constantly  present;  the  pulse  becomes  more 
rapid  and  weak,  and  the  respiration  is  irregular  and  often  of 
the  Cheyne-Stokes  variety.  Emaciation  becomes  more  marked, 
and  control  over  the  sphincters  is  completely  lost.  The  patient 
dies  in  this  state  from  exhaustion,  or  a  convulsive  seizure  may 
occur  and  terminate  the  illness. 

Course. — ^The  disease  usually  begins  with  evidences  of  a 
general  illness,  which  is  more  or  less  marked  in  a  child  or  an 
adult  who  either  has  tuberculosis  or  has  had  some  other  illness, 
or  who  is  pale  and  w^hose  resisting  power  is  poor,  or  it  may  appear 
in  a  child  who  is  previously  apparently  healthy.  In  other  cases 
the  disease  is  ushered  in  with  a  convulsion,  and  the  first  stage 
may  last  from  a  few  days  to  several  weeks. 

The  second  stage,  which  is  characterized  by  symptoms 
of  irritation  and  hyperesthesia  of  the  central  nervous  system, 
lasts  from  a  few  days  to  two  weeks,  rarely  longer. 

The  third  stage,  w^hich  is  marked  by  symptoms  pointing  to 
loss  of  function  of  the  central  nervous  system,  lasts  from  a 
few  days  to  one  or  two  weeks.  The  average  duration,  from 
the  onset  of  the  disease  to  its  fatal  termination,  is  about  four 
weeks. 

Prognosis. — The  prognosis  is  very  unfavorable:  a  few  re- 


SYPHILITIC    MENINGITIS  375 

coveries  have  been  reported,  but  in  the  vast  majority  of  cases 
the  outlook  is  hopeless. 

Diagnosis. — DitTerentiation  must  be  made  from  other  forms 
of  meningitis,  vascular  disturbances  of  the  brain,  hysteric 
conditions,  uremia,  catatonic  states  occurring  in  various  forms 
of  mental  disease,  cerebral  trauma,  etc. 

There  is  little  difficulty  in  arriving  at  a  correct  diagnosis 
if  the  history  of  the  condition  is  taken  into  consideration  and 
a  spinal  puncture  is  made.  The  cerebrospinal  fluid  is  usually 
increased  in  amount,  may  be  clear  or  slightly  turbid,  and  shows 
an  increase  in  its  cellular  constituents,  varying  in  number  from 
15  or  20  to  150  per  cmm.  These  cells  are  generally  of  the  small 
mononuclear  type.  There  is  an  absence  of  all  microorganisms 
except  the  tubercle  bacillus,  which  can  be  found  in  most  cases 
if  diligently  sought. 

Treatment. — The  patient  should  be  placed  in  a  quiet,  dark- 
ened, and  well-ventilated  room,  and  be  given  as  much  nourish- 
ment as  he  can  comfortably  take.  Pain  and  convulsions  should 
be  controlled  by  the  use  of  sedatives.  As  very  little  can  be 
done  for  this  condition,  it  is  important  that  its  occurrence  be 
prevented,  as  far  as  possible,  by  proper  attention  to  the  care 
and  surroundings  of  children  who  display  a  tubercular  tendency 
or  who  already  have  tuberculosis. 

SYPHILITIC   MENINGITIS 

This  form  of  meningitis  occurs  during  the  second  stage  of 
syphilis,  and  is  due  to  the  presence  of  the  Spirochasta  pallida. 
It  usually  appears  within  the  first  few  years  after  infection  has 
taken  place.  Injury  to  the  head,  mental  exhaustion,  worry, 
etc.,  may  act  as  exciting  causes  of  this  condition. 

Pathology. — In  this  form  of  meningitis  a  gummy  deposit 
is  usually  seen  in  the  subarachnoid  tissues,  and  round-cells 
infiltrate  the  cerebral  tissues.  As  a  rule,  the  exudate  is  first 
deposited  in  the  region  of  the  two  cerebral  peduncles,  and  spreads 
irregularly,  especially  around  the  blood-vessels.  The  ner^^es  at 
the  base  of  the  brain  are  also  usually  surrounded  and  even 
infiltrated   by   the   exudate.     This   gummy   exudate   may   be 


376  MANUAL  OF  NERVOUS  DISEASES 

localized  and  form  a  tumor-like  mass,  or  may  be  very  diffuse  in 
its  distribution.  In  some  few  cases  it  may  develop  first  on  the 
convexity  of  the  brain. 

Histologic  examination  of  the  exudate  shows  it  to  consist  of 
granulation  tissues  rich  in  cells  and  containing  many  small 
vessels.  This  exudate  is  never  purulent.  The  round-cells 
infiltrate  the  walls  of  the  vessels  and  the  epineurium  of  the 
nerves.  As  the  result  of  this  infiltration  the  walls  of  the  vessels 
become  thickened,  and  their  lumina  decreased  or  obliterated. 
The  nerve  becomes  swollen  as  the  result  of  the  infiltration,  and 
the  individual  fibers  may  become  atrophied  as  the  result  of  the 
pressure. 

Symptoms. — A  person  affected  with  a  syphilitic  meningitis 
will  complain  of  more  or  less  persistent  headache,  which  may  be 
very  severe,  and  which  usually  grows  worse  toward  evening 
and  at  night.  Attacks  of  vomiting,  vertigo,  disturbance  of  con- 
sciousness, or  convulsions  may  also  occur.  Quite  early  in  the 
condition  it  is  noticed  that  there  are  disturbances  of  memory, 
and  that  the  individual  is  more  or  less  indifferent.  There  may 
be  attacks  of  prolonged  stupor  or  of  excitement,  during  which  the 
patient  is  confused  and  delirious.  To  these  symptoms  are 
usually  added  evidences  of  interference  with  the  functions  of 
the  cranial  nerves. 

When  the  oculomotor  nerves  are  affected,  ptosis,  paralysis 
of  any  or  all  of  the  external  ocular  muscles,  and  pupillary  dis- 
turbances appear.  As  this  disease  may  involve  the  whole  or 
only  a  part  of  the  oculomotor  nerves,  there  may  be  either  a 
limited  or  an  extensive  involvement  of  the  ocular  muscles. 
The  optic  nerve  is  also  frequently  involved,  giving  rise  to  either 
unilateral  or  bilateral  optic  neuritis  or  choked  disk.  The  first 
nerve  may  be  involved,  causing  loss  of  the  sense  of  smell. 
If  the  seventh  nerves  are  involved,  facial  paralysis  and  inter- 
ference with  hearing  occur.  It  is  not  unusual  for  the  cranial 
nerves  to  be  irregularly  affected.  The  involvement  of  the 
cranial  nerves  varies  considerably,  and  is  inconstant.  To  these 
symptoms  are  frequently  added  those  of  involvement  of  the 
cerebral  vascular  system.  These  usually  develop  late  in  the 
disease.     As  a  rule,  there  is  little  or  no  increase  in  temper- 


SYPHILITIC   MENINGITIS  377 

ature.  The  clinical  picture  varies  greatly,  owing  to  the  fact 
that  the  exudate  may  be  limited  or  very  extensive  in  its  dis- 
tribution. 

Course. — As  a  rule,  the  onset  of  the  disease  is  very  insidious, 
headache  preceding  the  other  symptoms  for  a  considerable 
period.  In  a  few  cases  the  onset  may  be  very  acute.  The 
disease  usually  pursues  a  more  or  less  chronic  course,  character- 
ized by  repeated  remissions  and  exacerbations,  periods  occurring 
during  which  the  patient  seems  almost  well. 

Prognosis. — The  prognosis  is  generally  favorable  if  the 
condition  is  recognized  early.  It  is  only  after  the  disease  has 
existed  for  some  time  and  the  nerves  have  undergone  atrophic 
changes  that  recovery  cannot  be  hoped  for.  In  those  cases  in 
which  repeated  apoplectic  attacks  have  occurred  the  outlook  is 
unfavorable. 

Diagnosis. — ^This  condition  is  differentiated  from  tumor  oj 
the  brain  by  the  history,  the  variability  of  the  symptoms,  the 
distribution,  and  the  irregular  involvement  of  the  structures  at 
the  base  of  the  brain.  Examination  of  the  blood  and  spinal 
fluid  and  the  effect  of  treatment  are  additional  aids  to  diag- 
nosis. 

It  is  very  difficult  at  times  to  differentiate  this  disease  from 
general  paresis.  Usually  the  diagnosis  of  general  paresis  can 
be  made  from  the  history  of  very  slow  onset,  the  primary  in- 
fection having  occurred  many  years  previously  from  the  promi- 
nence of  the  mental  symptoms  and  the  absence  of  headache. 
In  some  cases  differentiation  between  the  two  diseases  can  be 
made  only  as  the  result  of  treatment,  syphilitic  meningitis 
usually  responding  well  to  treatment,  whereas  general  paresis 
responds  only  indifferently  if  at  all. 

From  other  forms  of  meningitis  this  disease  is  differentiated 
by  the  absence  of  temperature  and  the  result  of  examination  of 
the  cerebrospinal  fluid. 

Treatment.— Energetic  antisyphilitic  treatment  should  be 
instituted  at  once  whenever  there  is  even  a  suspicion  of  a 
syphilitic  brain  condition.  The  treatment  should  consist  of 
the  intravenous  injection  of  salvarsan.  Three  days  after  this 
mercurial  inunctions  should  be  given  daily  for  three  weeks,  and 


378  MANUAL   OF   NERVOUS   DISEASES 

potassium  iodid  in  appropriate  doses  internally.  At  the  end  of 
four  weeks  a  second  injection  of  salvarsan  should  be  given,  and 
mercurial  inunctions  and  potassium  iodid  again  resumed.  In 
those  cases  in  which  the  cerebrospinal  fluid  yields  a  positive 
Wassermann  reaction,  intradural  and  in  some  cases  intraven- 
tricular injections  of  salvarsanized,  mercurialized  serum  should 
be  given.  The  antisyphilitic  treatment  should  be  continued  until 
the  blood  and  spinal  fluid  yield  a  negative  Wassermann  reaction. 
The  general  health  of  the  patient  should  receive  attention.  The 
diet  should  be  properly  supervised,  and  diversion,  fresh  air,  and 
exercise  prescribed. 

In  those  cases  in  which  the  symptoms  point  to  a  localized 
pathogenic  state  which  does  not  yield  to  antisyphilitic  treat- 
ment, surgical  intervention  is  justifiable.  It  is  most  important 
that  syphilitic  infection  should  be  promptly  and  thoroughly 
treated  so  as  to  prevent  the  occurrence  of  subsequent  syphilitic 
diseases  of  the  nervous  system. 

SEROUS  MENINGITIS— MENINGISMUS 

This  is  a  condition  characterized  by  many  of  the  symptoms 
of  meningitis,  the  cerebrospinal  fluid  being  usually  increased 
in  amount  and  not  purulent,  and  containing  no  pathogenic 
organisms. 

Etiology. — It  occurs  as  a  sequel  to  a  purulent  meningitis, 
in  some  cases  of  internal  hydrocephalus,  after  injury,  chronic 
toxemia,  especially  alcoholism,  acute  infectious  diseases,  delirium 
tremens,  chronic  nephritis,  and  prolonged  gastro-intestinal 
disorders. 

Pathology. — ^The  brain  and  membranes  are  either  injected  or 
pale  and  edematous.  The  ventricles  are  dilated,  and  the  peri- 
vascular and  pericellular  spaces  are  dilated  and  contain  fluid. 
The  nerve-cells  show  signs  of  degeneration. 

Symptoms. — ^The  patient  complains  of  headache;  cervical 
rigidity,  marked  restlessness,  and  general  hyperesthesia  are 
present.  Some  cases  are  ushered  in  with  delirium  and  marked 
restlessness,  which  merges  into  a  semicomatose  condition, 
accompanied  by  a  muttering  delirium  and  perhaps  flitting 
delusions  and  hallucinations. 


SEROUS    MENINGITIS — MENINGISMUS  379 

The  tongue  is  usually  coated  and  dry,  the  pulse  rapid,  and 
there  is  little  or  no  temperature.  Weakness,  but  not  paralysis, 
of  the  extremities  is  present.  The  pupillary  reaction  is  sluggish, 
and  the  patient  becomes  indifferent  to  the  passage  of  urine  and 
feces. 

As  the  condition  becomes  more  marked  the  coma  deepens, 
and  the  temperature  may  rise.  The  skin  loses  its  elasticity, 
and  when  picked  up  and  pinched  remains  elevated  for  some 
time;  this  condition  is  known  as  "putty  skin."  The  pulse 
becomes  more  rapid  and  feeble,  and  bed-sores  may  develop,  the 
patient  dying  either  from  a  secondary  pneumonia  or  from 
cardiac  exliaustion.  Many  cases  do  not  pass  into  this  stage, 
the  mind  becoming  clearer,  the  hyperesthesia  and  restlessness 
decreasing,  and  the  patient  going  on  to  recovery.  The  cerebro- 
spinal fluid  is  markedly  increased  in  amount,  and  it  is  clear  and 
does  not  contain  pathogenic  organisms. 

Course. — During  the  course  of  an  otitis  media,  or  following 
an  injury,  prolonged  intoxication,  etc.,  s>Tiiptoms  of  a  menin- 
gitis may  occur  that  do  not  present  marked  local  manifes- 
tations, or  severe  and  persistent  pyrexia.  This  condition 
may  clear  up  within  twenty-four  hours,  or  may  run  a  prolonged 
course,  lasting  many  days,  weeks,  or  even  months,  during 
which  exacerbations  and  remissions  in  the  symptoms  may 
manifest  themselves. 

The  prognosis  varies:  those  cases  in  which  the  symptoms 
appear  as  the  result  of  an  irritation  of  the  cerebral  membranes, 
in  young  individuals,  usually  present  a  very  good  prognosis. 
When  the  condition  occurs  in  adults,  after  prolonged  intoxica- 
tion, the  prognosis  is  unfavorable. 

Diagnosis. — ^This  condition  must  be  differentiated  from  other 
forms  of  meningitis:  in  suppurative  meningitis  the  temperature 
is  usually  higher,  there  is  a  leukocytosis,  and  the  cerebrospinal 
fluid  is  purulent  and  contains  pathogenic  organisms ;  in  tubercular 
meningitis  the  onset  is  more  insidious,  delirium  and  restlessness 
are  less  marked,  and  local  symptoms,  pointing  to  involvement 
of  the  base  of  the  brain,  are  commonly  present. 

Treatment. — ^The  patient  should  be  placed  in  bed,  in  a  quiet, 
well-ventilated,  and  darkened  room.     He  should  be  constantly 


380  MANUAL  OF  NERVOUS  DISEASES 

watched  by  efficient  nurses  to  prevent  injury.  Care  should  be 
exercised  to  prevent  the  development  of  bed-sores,  and  attention 
should  be  paid  to  the  proper  emptying  of  the  bladder  and  rectum. 
A  careful  examination  is  to  be  made  to  remove  the  cause  of 
irritation  if  possible.  In  those  cases  secondary  to  an  acute 
otitis  media  operations  upon  the  ear  or  mastoid  may  be  followed 
by  immediate  disappearance  of  the  symptoms.  Lavage  of  the 
stomach  and  free  purgation  should  be  promptly  instituted  in 
those  cases  that  are  caused  by  gastro-intestinal  derangements, 
and  subsequent  regulation  of  the  diet  should  be  instituted. 
Ice-caps  should  be  applied  to  the  head,  and  mild  counterirritation 
along  the  course  of  the  spine.  The  pulse  should  be  sustained 
with  strychnin.  Fluids  should  be  given  in  sufficient  quantities. 
Most  important  is  spinal  puncture,  the  withdrawal  of  cerebro- 
spinal fluid  being  frequently  followed  by  marked  improvemicnt 
in  the  symptoms;  this  should  be  repeated  within  twenty-four 
hours  if  necessary. 

CEREBRAL   ANEMIA 

Etiology. — Anemia  of  the  brain  may  be  produced  by  the  loss 
of  a  large  amount  of  blood,  by  obstruction  of  the  blood-supply  to 
the  brain,  by  cardiac  weakness,  and  by  spasmodic  contractions 
of  the  cerebral  arteries.  It  also  occurs  in  diseased  states  of  the 
blood,  as  the  result  of  emotional  disturbances,  such  as  excite- 
ment, fear,  anger,  grief,  shock,  physical  pain,  childbirth,  etc. 
Neurotic  individuals  are  predisposed  to  attacks  of  cerebral 
anemia. 

Symptoms. — ^The  onset  of  the  disease  may  be  either  acute  or 
chronic.  If  the  cerebral  anemia  comes  on  acutely,  there  are 
usually  disturbance  of  consciousness,  nausea,  vomiting,  tinnitus 
aurium,  and  vertigo;  the  individual  feels  weak,  and  there  is  a 
sense  of  heaviness,  anxiety,  or  indifference.  If  the  interference 
with  the  blood-supply  to  the  brain  is  very  extensive,  uncon- 
sciousness supervenes,  the  pupils  become  dilated,  the  reflexes 
are  lost,  and  convulsions  may  occur. 

The  face  and  the  mucous  membranes  are  usually  pale.  The 
skin  feels  cold,  and  may  be  covered  with  profuse  perspiration. 
In  the  milder  degrees  of  cerebral  anemia  the  patient  becomes 


CEREBRAL   ANEMIA  38 1 

faint,  is  depressed,  and  only  partially  loses  consciousness, 
everything  appearing  indistinct  before  his  eyes.  He  usually 
falls  slowly  to  the  ground.  The  pulse  is  generally  small  and 
rapid,  and  breathing  is  slow,  rapid,  or  irregular.  The  attacks 
may  last  from  a  few  minutes  to  an  hour  or  more.  In  those  cases 
in  which  the  cerebral  anemia  is  of  more  gradual  onset  and  of 
longer  duration,  giving  rise  to  a  chronic  cerebral  anemia,  the 
patient  complains  of  symptoms  that  are  usually  more  marked 
when  he  is  in  an  upright  position,  and  less  marked  when  he  is 
lying  down. 

These  patients  complain  of  insomnia  or  a  constant  drowsiness 
and  disturbance  of  the  memory.  There  is  a  tendency  to  syncope 
upon  the  least  exertion,  and  more  or  less  constant  vertigo  and 
tmnitus  aurium  are  present.  The  patients  also  complain  of 
discomfort  in  the  head,  and  at  times  delirium  develops. 

Course. — The  course  is  largely  dependent  upon  the  etiology. 
The  attack  may  come  on  suddenly;  in  cases  due  to  chronic 
cerebral  anemia  there  are  more  or  less  constant  cerebral  s\Tnp- 
toms,  which  are  aggravated  upon  exertion,  and  are  more  marked 
with  the  patient  in  the  erect  posture  than  when  he  is  reclining. 

The  prognosis  depends  upon  the  cause.  In  the  less  severe 
cases  the  outlook  for  recovery  from  the  attack  is  good;  in  the 
more  severe  forms,  in  which  convulsions  occur  and  the  pupillary 
reflexes  are  lost,  the  prognosis  is  unfavorable,  as  the  patient  may 
die  during  the  attack  or  following  it.  There  may  be  s}TQptoms 
pointing  to  cerebral  degeneration. 

Treatment. — This  consists  in  treating  the  attack  and  also 
the  cause.  Treatment  of  the  cause  resolves  itself  into  making 
a  careful  examination  to  discover  the  underlying  condition. 
In  neurotic  individuals,  or  in  those  hereditarily  predisposed, 
their  reeducation,  cautioning  them  to  avoid  excitement  and  to 
exert  self-control,  and  the  general  building-up  of  the  bodily 
condition,  are  the  indications. 

Treatment  of  the  attack :  The  patient  should  be  placed  in  the 
horizontal  position,  w'ith  the  head  as  low  as  possible.  Circula- 
tion should  be  stimulated  by  sprinkling  cold  w^ater  on  the  skin, 
applying  spirits  of  ammonia  to  the  nostrils,  and  administering 
stimulants  by  mouth  or  hj-podermically. 


382  MANUAL   OF   NERVOUS   DISEASES 

CEREBRAL   HYPEREMIA 

Increase  in  the  amount  of  blood  present  in  the  brain  may  be 
the  result  of  interference  with  the  venous  circulation,  or  may  be 
caused  by  an  increased  amount  of  blood  being  sent  to  the 
brain.  In  the  former  the  hyperemia  is  passive,  and  in  the 
latter,  active. 

Etiology. — Overeating,  reflex  irritation,  increase  in  the  blood- 
pressure,  mental  activity,  overindulgence  in  alcoholic  liquors, 
vasomotor  instability,  disturbances  of  menstruation,  compression 
of  the  jugular  veins  by  tumors  or  enlarged  glands,  pressure 
upon  the  superior  vena  cava,  certain  drugs,  such  as  nitro- 
glycerin, amyl  nitrite,  etc.,  sunstroke,  sudden  changes  in  position 
and  physical  exertions,  etc.,  are  all  among  the  causes. 

Pathology. — ^The  cortex  and  white  matter  of  the  brain  present 
a  pinkish  appearance,  there  is  an  increase  in  tKe  cerebrospinal 
fluid,  and  the  blood-vessels  and  sinuses  are  overdistended. 
The  veins  stand  out  prominently  on  the  cerebral  cortex,  and  at 
times  pulsation  can  be  noticed  in  the  vessels. 

Symptoms. — Cerebral  hyperemia  may  occur  either  acutely  or 
subacutely,  or  may  develop  into  a  chronic  condition.  If  the 
attacks  are  acute,  there  may  be  loss  of  consciousness,  mental 
confusion  or  delirium,  and  a  mild  degree  of  fever.  These  symp- 
toms may  be  accompanied  by  paralysis  or  weakness,  disturbances 
of  speech,  and  convulsions;  they  are  generally  of  brief  duration, 
complete  recovery  being  the  rule. 

If  the  attack  occurs  subacutely,  the  patient  presents  a  more 
or  less  flushed  appearance;  the  conjunctivae  are  injected,  and 
he  complains  of  headache,  mental  dulness  or  irritability,  rest- 
lessness or  somnolence,  and  more  or  less  constant  tinnitus  and 
vertigo.  In  chronic  hyperemia  there  are  mental  heaviness,  a 
tendency  to  a  state  of  confusion,  restlessness,  and  at  times  drow- 
siness or  insomnia,  inability  to  perform  mental  work,  headache, 
and  the  like.  Symptoms  due  to  cerebral  hyperemia  are  usually 
aggravated  when  the  patient  is  in  the  recumbent  position,  or 
when  changes  of  position  cause  the  head  to  be  lowered.  They 
generally  subside  when  the  patient  assumes  the  upright  posi- 
tion. 


RUPTURE    OR    OCCLUSJON    OF    CEREBRAL    ARTERIES      383 

Diagnosis. — A  diagnosis  of  cerebral  hyperemia  is  less  fre- 
quently made  at  present  than  formerly,  since  proper  examination 
will  generally  reveal  the  presence  of  the  underlying  condition 
that  is  responsible  for  the  disturbances  in  the  cerebral  circulation. 

Prognosis. — The  prognosis  depends  entirely  upon  the  cause. 
In  the  few  cases  in  which  the  attacks  are  not  severe  and  of  short 
duration  the  prognosis  is,  as  a  rule,  good. 

Treatment. — Cerebral  congestion  is  to  be  prevented  by  avoid- 
ing excesses  of  all  kinds,  such  as  physical  overexertion,  etc., 
and  by  giving  proper  attention  to  the  gastro-intestinal  tract. 
Alcoholic  liquors  should  be  eschew^ed,  and  the  patient  should 
lead  a  life  as  free  from  excitement  and  worry  as  possible. 

Any  of  the  causative  conditions  that  are  revealed  upon 
physical  examination  should  be  properly  treated.  During  the 
attack  the  patient's  head  should  be  elevated,  and  cold  applica- 
tions made  to  the  head.  Hot  mustard  foot-baths  are  useful. 
All  constricting  clothing  should  be  removed,  and  the  room 
should  be  cool  and  well  ventilated.  If  the  attack 'is  very  severe 
and  persistent,  purgatives  are  to  be  administered,  and  in  some 
cases  it  may  be  necessary  to  employ  blood-letting.  If  there  is 
much  restlessness,  the  bromids  may  be  given. 


RUPTURE  OR  OCCLUSION  OF  THE  CEREBRAL  ARTERIES 

Etiology. — Rupture  or  occulusion  of  a  cerebral  vessel  may 
occur  at  any  age.  It  may  take  place  during  birth,  as  the  result 
of  pressure  or  injury;  during  early  childhood,  following  injury, 
endocarditis,  convulsions,  etc.  The  greatest  number  of  cases 
occur  between  the  fortieth  and  the  sixtieth  years.  Males  are 
more  frequently  attacked  than  females.  In  some  families 
there  is  a  distinct  hereditary  predisposition  to  the  occurrence 
of  disease  of  the  cerebral  blood-vessels. 

Disturbance  of  the  cerebral  circulation  is  due  to  disease  of 
the  blood-vessels,  w^hich  causes  either  a  weakness  of  the  vessel 
walls,  predisposing  to  rupture,  or  decrease  in  the  size  of  the 
lumina  of  vessels,  thereby  preventing  an  adequate  amount  of 
blood  from  reaching  the  cerebral  substance;  to  trauma,  rupturing 


384  MANUAL   OF   NERVOUS.  DISEASES 

or  compressing  a  vessel ;  to  some  particle  that  enters  or  is  present 
in  the  blood-stream,  and  is  carried  into  a  cerebral  vessel,  thereby 
suddenly  occluding  its  lumen ;  to  an  abnormal  state  of  the  cardiac 
muscles  whereby  the  force  of  the  circulation  is  either  deficient  or 
increased;  to  diseased  states  of  the  blood  itself. 

We  find,  therefore,  that  the  causes  of  disordered  functions 
of  the  brain  due  to  a  disturbed  circulation  are  principally  those 
that  bring  about  diseased  states  of  the  blood-vessels,  the  heart, 
and  the  blood.  Among  the  more  common  conditions  that 
cause  diseased  states  of  the  cardiovascular  system  are  syphilis, 
chronic  intoxications,  such  as  alcohol  and  lead-poisoning,  etc.; 
chronic  gastro-intestinal  auto-intoxication;  excessive  ingestion 
of  proteins ;  old  age ;  heavy  work ;  w^orry ;  prolonged  constitutional 
diseases,  such  as  gout,  rheumatism,  nephritis,  infectious  dis- 
eases, particularly  typhoid  fever,  heredity,  etc. 

Diseases  that  bring  about  or  that  are  accompanied  by  a 
myocarditis,  cardiac  hypertrophy,  or  endocarditis,  or  such 
diseases  as  leukemia,  pernicious  anemia,  or  purpura,  all  pre- 
dispose to  the  occurrence  of  rupture  or  occlusion  of  a  cerebral 
blood-vessel.  Among  the  exciting  causes  are  emotional  excite- 
ment, physical  exertion,  trauma,  overeating,  exhaustion,  mental 
depression,  physical  weakness,  shock,  coughing,  convulsions, 
overindulgence  in  alcoholic  liquors,  constipation,  etc. 

Pathology. — As  the  result  of  any  of  the  predisposing  causes  a 
disturbance  of  the  cerebral  circulation  may  take  place,  bringing 
about  one  of  three  conditions:  (i)  A  vessel  may  rupture  and 
result  in  hemorrhage  into  or  upon  the  brain ;  (2)  the  vessel  may 
be  gradually  occluded,  thereby  depriving  the  brain  substance 
more  or  less  completly  of  nourishment,  and  causing  a  gradual 
wasting  away  of  the  brain  substance;  (3)  a  vessel  may  be 
suddenly  occluded,  bringing  about  an  abrupt  cutting  off  of  the 
nourishment  of  the  portion  of  the  brain  supplied  by  that  vessel ; 
if  this  occlusion  is  permanent,  it  will  result  in  a  softening  and 
shrinkage  of  that  part  of  the  brain  supplied  by  the  occluded 
vessel. 

A  sclerosis  of  the  peripheral  blood-vessels  may  exist  without 
a  similar  condition  of  the  cerebral  vessels,  or  a  sclerosis  of  the 
cerebral  vessels  may  be  present  without  a  corresponding  sclerosis 


RUPTURE  OR  OCCLUSION  OF  CEREBRAL  ARTERIES   385 

of  the  peripheral  vessels.  As  a  rule,  however,  the  condition 
of  the  peripheral  vessels  is  a  fairly  accurate  index  as  to  the  con- 
dition of  the  cerebral  vessels. 

Disease  of  the  blood-vessels  may  result  in  the  formation  of 
new  cellular  tissue,  affecting  the  endothelial  lining  of  the  vessels, 
causing  a  gradual  obliteration  of  the  lumen;  or  the  middle 
coat  of  the  vessel  may  undergo  calcareous  degeneration,  with 
absorption  of  the  inner  layer  of  the  vessel,  causing  a  roughening 
of  the  walls.  On  these  roughtened  areas  fibrin  may  be  deposited, 
which  may  gradually  occlude  the  vessel  or  be  carried  off  as 
emboli;  or  the  walls  of  the  vessels  may  undergo  degenerative 
changes,  become  weakened,  and  thus  permit  the  formation  of 
small  or  large  aneurysms.  Following  these  degenerative 
changes,  either  with  or  without  the  production  of  the  aneurysms, 
there  is  a  marked  predisposition  to  rupture  and  the  occurrence 
of  hemorrhage. 

Hemorrhage  may  occur  either  on  or  into  the  brain  substance. 
When  a  cerebral  vessel  ruptures  in  the  membrane,  the  blood 
spreads  out  on  the  surface  of  the  brain,  beneath  the  arachnoid, 
filling  in  the  fissures.  If  the  amount  is  very  large,  it  gradually 
compresses  the  brain.  If  the  blood  is  not  evacuated,  a  clot 
forms,  w^hich  may  be  absorbed,  the  space  that  was  occupied  by 
the  clot  being  filled  by  the  cerebrospinal  fluid.  In  some  cases, 
especially  in  older  individuals  and  in  alcoholics,  the  clot  becomes 
organized  and  adherent  to  the  cerebral  membranes.  If  hemor- 
rhage into  the  cerebral  substance  occurs,  it  destroys  the  surround- 
ing brain  tissue.  The  amount  of  blood  lost  varies  from  a  very 
small  quantity  to  large  amounts;  the  destruction  of  the  cerebral 
tissue  may  be  limited  to  a  small  area  or  may  involve  the  entire 
hemisphere.  More  than  60  per  cent,  of  cerebral  hemorrhages 
occur  as  the  result  of  rupture  of  the  lenticulostriate  or  lenticulo- 
thalamic  arteries;  these  arteries  are  termed  by  Charcot  the  hem- 
orrhagic arteries  of  the  brain.  Owing  to  the  fact  that  those  on  the 
left  side  receive  the  impulses  from  the  heart  more  directly  than 
those  on  the  right  there  is  a  slightly  greater  tendency  for  vessels 
to  rupture  on  the  left  side  of  the  brain  than  on  the  right.  A 
hemorrhage  occurring  from  these  vessels  destroys,  more  or  less 
completely,  the  lenticular  nucleus,  the  optic  thalamus  or  caudate 


386 


MANUAL   OF   NERVOUS  DISEASES 


nucleus,  and  that  portion  of  the  internal  capsule  in  the  affected 
region.  If  the  hemorrhage  is  very  extensive,  it  may  invade  the 
ventricles  (Figs.  137,  138). 

In  about  20  per  cent,  of  cases  the  hemorrhage  occurs  on 
the  cortex  of  the  brain,  as  the  result  of  rupture  of  miliary 
aneurysms  on  the  surface  vessels  of  the  brain.  In  a  few  cases 
hemorrhage  has  its  origin  in  a  ruptured  ventricular  vessel,  and 
in  others  hemorrhage  occurs  in  or  on  the  brain-setm.  Only 
rarely  does  hemorrhage  into  the  cerebellum  occur. 


Fig.  137. — Cerebral  hemorrhage  in  internal  capsule. 

After  a  hemorrhage  into  the  brain-substance  has  occurred,  a 
clot  forms,  which  is  usually  irregular  in  shape.  The  brain 
tissue  around  the  clot  is  compressed  and  edematous;  gradually 
the  clot  shrinks,  the  edema  disappears,  and  as  time  goes  on 
there  is  a  gradual  softening  and  absorption  of  the  clot  and  of 
the  disintegrated  brain  tissue.  Eventually  there  remains  an 
area  of  connective  tissue  which  may  be  pigmented.  In  a  few 
cases  a  cyst  forms  during  the  course  of  the  absorption  of  the 
clot. 

After  a  hemorrhage  has  taken  place  the  clot  begins  to  lose  its 


RUPTURE    OR    OCCLUSION    OF    CEREBRAL    ARTERIES      387 

reddish  color  in  from  the  second  to  the  fifth  week,  and  in  the 
eighth  to  the  twelfth  week  it  becomes  yellowish.  Connective- 
tissue  formation  is  well  established  within  sLx  months,  and  con- 
traction of  the  connective  tissue  continues  until  the  end  of  the 
second  year. 

As  the  result  of  destruction  of  the  brain  tissue  secondary 
degeneration  begins  at  once,  and  by  the  end  of  the  second  week 
this  degeneration  can  be  detected  at  remote  points  from  the 
original  lesion.     In  such  diseases  as  purpura,  pernicious  anemia, 


Fig.  138. — Brain,  sho\^•ing  extensive  hemorrhage  into  ventricle. 

etc.,  there  may  be  extravasation  of  blood  without  apparent 
rupture  of  vessels.  In  these  diseases  the  blood  collects  about 
the  vessels  and  infiltrates  and  comxpresses  the  brain  tissue  in  the 
vicinity  of  the  vessels,  bringing  about  interference  with  or  com- 
plete loss  of  the  functions  of  the  afi'ected  portions  of  the  brain. 
The  lumen  of  the  cerebral  vessel  may  be  gradually  occluded 
as  the  result  of  thickening  and  proliferation  of  the  endothelial 
lining,  leading  to  gradual  interference  with  the  blood-supply 
of  the  part  of  the  brain  nourished  by  the  diseased  vessel;  or  the 


388  MANUAL   OF  NERVOUS   DISEASES 

lumen  of  a  vessel  may  be  suddenly  occluded  by  an  embolus 
coming  from  some  distant  point,  such  as  the  heart,  other  blood- 
vessels, the  lungs,  etc.,  or  by  a  clot  forming  upon  the  roughened 
wall  of  a  diseased  vessel.  In  this  condition  there  is  a  sudden 
interference  with  the  blood-supply  of  the  part  of  the  brain 
nourished  by  the  occluded  vessel;  usually  this  is  at  first  very 
extensive.  In  addition  to  the  interference  with  the  blood- 
supply  there  is  also,  as  a  rule,  an  edema  of  the  surrounding 
cerebral  tissues. 

Owing  to  the  fact  that  there  is  a  free  anastomosis  of  the 
vessels  upon  the  surface  of  the  brain,  shortly  after  one  of  these 
vessels  is  occluded  a  free  collateral  circulation  takes  place, 
and  the  cerebral  tissues  again  receive  their  blood-supply.  The 
vessels  that  penetrate  the  brain  substance  are  all  terminal 
vessels;  if,  therefore,  they  become  occluded,  the  portion  of  the 
brain  supplied  by  them  is  permanently  deprived  of  its  nourish- 
ment, and  consequently  undergoes  degenerative  changes.  As 
the  result  of  the  deprivation  of  blood  the  cerebral  tissues  undergo 
softening,  with  degeneration  of  the  cellular  constituents.  At 
times  there  is  an  extravasation  of  blood  into  the  softened  area, 
when  the  condition  is  known  as  red  softening. 

Following  the  degenerative  changes  the  softened  tissue  under- 
goes liquefaction,  or  becomes  organized  by  connective-tissue 
growth :  in  the  former  case  a  cyst  is  produced  with  smooth  walls 
(Fig.  139),  and  in  the  latter  case  there  is  left  connective  tissue 
or  a  scar  in  the  cerebral  tissue.  The  size  of  the  area  of  softening 
depends  upon  the  area  of  cerebral  tissue  supplied  by  the  occluded 
vessel.  In  those  cases  in  which  the  occluding  agent  contains 
pathogenic  microorganisms  there  is  added  to  the  pathologic 
changes  that  result  from  interference  with  the  blood-supply  the 
evidence  of  an  acute  encephalitis  of  more  or  less  limited  extent. 

Owing  to  the  fact  that  the  circulation  from  the  heart  is  more 
direct  to  the  left  side  of  the  brain  and  to  the  middle  cerebral 
artery,  60  per  cent,  of  emboli  are  carried  into  the  left  middle 
cerebral  artery  or  its  branches. 

Symptoms. — The  symptoms  of  disturbance  of  the  blood-sup- 
ply of  the  brain  may  in  most  cases  be  divided  into  two  periods 
— the  first  period,  during  which  there  is  a  partial,  temporary,  or 


RUPTURE    OR   OCCLUSION    OF    CEREBRAL   ARTERIES      389 

intermittent  disturbance  of  the  blood-supply;  the  second 
period,  during  which  there  is  a  more  or  less  sudden  complete 
interference  with  the  supply  of  blood  to  a  definite  area  in  the 
brain,  or  there  occurs  a  rupture  of  a  vessel  with  the  extravasa- 
tion of  blood. 

The  symptoms  occurring  in  the  first  period  are  called  the 
premonitory  symptoms:  they  are  the  general  symptoms  and 
signs   of   cardiovascular   diseases,   such  as   rapid  or   irregular 


Fig.  139. — Cystic  formation  following  vascular  occlusion. 

pulse,  high  or  low  blood-pressure,  valvular  murmurs,  thickened 
and  tortuous  vessels,  disturbance  of  the  heart  sounds,  evidence 
of  chronic  interstitial  nephritis,  gastric  disturbances,  etc. 
With  or  without  these  there  usually  occur  symptoms  pointing 
to  disturbance  of  the  cerebral  circulation.  Of  these,  the  com- 
monest is  headache,  which  is  generally  of  a  dull  character,  and 
grows  worse  on  exertion,  excitement,  or  by  anything  that  tends 
to  weaken  the  individual.  These  headaches  are  not  usually 
continuous,  but  come  on  in  attacks  that  vary  in  frequency  and 


390  MANUAL   OF   NERVOUS   DISEASES 

severity.  Attacks  of  vertigo  appear,  which  vary  in  severity 
and  come  on  at  irregular  intervals,  usually  after  exertion, 
emotional  disturbance,  excitement,  etc.  Paresthesia:  Nearly 
all  patients  with  vascular  disease  of  the  brain  at  some  time  or 
other  complain  of  numbness,  tingling,  formication,  etc;  these 
abnormal  sensations  may  be  limited  to  one  entire  limb  or  to 
one-half  of  the  body;  on  the  other  hand,  these  sensations  may 
affect  the  terminal  portions  of  all  four  extremities. 

Disturbances  of  speech,  the  patient  finding  it  difficult  to 
express  his  thoughts  in  words,  occur  at  intervals,  but  usually 
rapidly  disappear.  Many  of  these  individuals  will  also  com- 
plain of  loss  of  memory,  especially  for  recent  events;  difficulty 
in  fixing  the  attention  on  important  matters,  there  being  a 
constant  tendency  for  the  mind  to  wander;  difficulty  in  thinking, 
abnormal  irritability,  and  a  tendency  to  become  emotional. 

In  the  more  advanced  cases  attacks  of  confusion  or  stupor  may 
occur.  Disturbance  of  sleep  may  also  arise,  the  patient  being 
very  restless  on  going  to  bed,  and  unable  to  sleep  until  toward 
morning;  other  patients  go  to  sleep  almost  immediately  upon 
retiring,  but  awaken  after  a  few  hours  and  find  it  impossible 
to  go  to  sleep  again.  Others  may  be  drowsy  and  sleep  almost 
the  entire  day,  but  will  be  unable  to  sleep  during  the  night. 
Tinnitus  aurium,  visual  disturbances,  etc.,  may  also  occur. 

In  some  patients  there  will  be  attacks  of  weakness,  or  even 
paralysis,  affecting  one  limb  or  one  side  of  the  body;  these 
attacks  are  of  short  duration.  These  premonitory  symptoms 
may  occur  over  a  period  of  many  years  before  evidence  point- 
ing to  permanent  occlusion  or  rupture  manifests  itself.  On 
the  other  hand,  in  some  cases,  without  the  appearance  of  any 
of  these  premonitory  signs,  there  will  be  symptoms  pointing  to 
rupture  or  occlusion  of  a  vessel.  This  condition  is,  of  course, 
in  many  cases  easily  explainable.  In  some  cases  an  embolus 
is  carried  from  the  heart  or  some  large  vessel  to  a  cerebral 
vessel,  which  it  suddenly  occludes.  This  may  occur  in  one 
who  has  previously  had  no  disease  of  the  cerebral  blood-vessels. 
Miliary  aneurysms  of  the  cerebral  vessels  may  give  rise  to  no 
symptoms,  and  yet  rupture,  when  for  some  reason  or  other 
there  is  an  increase  in  the  blood-pressure. 


RUPTURE    OR    OCCLUSION    OF    CEREBRAL    ARTERIES      39 1 

The  clinical  state  that  occurs  as  the  result  of  an  occlusion  or 
rupture  of  a  cerebral  vessel  is  termed  apoplexy.  An  apoplectic 
attack  usually  comes  on  more  or  less  suddenly,  and  is  character- 
ized by  evidences  of  the  loss  of  function  of  some  portion  of  the 
brain.  As  a  rule,  it  is  accompanied  by  considerable  mental 
shock.  In  some  cases  the  apoplectic  attack  may  come  on  slowly, 
covering  a  period  of  from  a  few  minutes  to  several  days. 

Symptoms  of  the  Attack. — In  about  half  the  cases  loss  of  con- 
sciousness occurs  simultaneously  with  the  attack;  the  degree 
and  duration  of  the  unconsciousness  servx  as  a  fairly  accurate 
index  of  the  severity  of  the  seizure. 

General  Constitutional  Symptoms. — There  are  two  types  of 
patients:  in  the  one  the  pulse  is  slow  and  regular,  the  blood- 
pressure  ranging  from  160  to  250;  the  face  is  flushed  or  cyanotic; 
the  breathing  is  stertorous  and  irregular;  the  conjunctivae  are 
injected,  and  the  temperature  ranges  from  the  normal  to  104° 
or  105°  F.  Edema  of  the  lungs  may  occur,  and  the  patient 
die  within  a  few  hours  or  davs,  either  from  cardiac  exhaustion 
or  from  pulmonary  edema. 

In  the  second  t}^e  of  cases  disturbances  of  consciousness 
are  not  so  marked,  and  in  some  they  are  very  slight;  the  pulse 
is  more  or  less  rapid,  and  perhaps  irregular;  the  blood-pressure 
is  low;  the  face  is  pale;  breathing  is  irregular  or  of  the  Cheyne- 
Stokes  variety,  and  there  is  no  temperature. 

In  some  cases  at  the  onset  of  the  attack  there  is  a  relaxation 
of  the  rectal  and  vesical  sphincters,  with  an  involuntary  evacua- 
tion of  the  contents  of  the  bladder  and  rectum.  In  those  cases 
attended  by  coma  the  patient  falls,  and  cannot  be  aroused;  he 
is  motionless  and  insensible,  and  the  face  is  usually  drawn  to 
one  side,  with  a  dribbling  of  saliva  upon  the  opposite  side. 
There  is  a  loss  of  the  skin  reflexes,  and  later  on  increased  tendon- 
reflexes.  Automatic  movements  may  occur  on  the  non-paralyzed 
side. 

Convulsive  movements  may  usher  in  the  attack  or  may  occur 
later  on.  Disturbance  of  consciousness  may  last  for  a  few 
hours,  and  be  followed  by  a  state  of  mental  torpidity  and  con- 
fusion that  may  last  several  days  or  weeks.  The  comatose 
state  is  apt  to  occur  in  hemorrhage  of  the  deeper  structures  of 


392  MANUAL   OF  NERVOUS   DISEASES 

the  brain,  or  in  occlusion  of  large  vessels.  Lesions  in  the  cere- 
bellum and  brain-stem  are  less  likely  to  be  accompanied  by 
disturbances  of  consciousness. 

Within  from  twenty-four  to  forty-eight  hours  after  the  attack 
it  is  usually  possible  to  determine  the  location,  the  extent, 
and  the  character  of  the  lesion. 

Location  of  the  Lesion. — In  lesions  on  the  surface  of  the  brain 
the  symptoms  are  generally  of  slower  onset  than  are  those 
occurring  in  the  deeper  structures;  they  manifest  themselves 
first  by  symptoms  of  irritation  of  the  cortex,  which  are  later 
replaced  by  those  of  paralysis.  Symptoms  due  to  lesions  on 
the  surface  of  the  brain  are  usually  much  more  circumscribed 
than  are  those  due  to  involvement  of  the  deeper  structures. 

Symptoms  pointing  to  involvement  of  the  anterior  part  of 
the  frontal  lobe  are  variable  and  indefinite:  there  may  be  emo- 
tional disturbance,  a  tendency  to  cry  and  laugh  without  cause, 
changes  in  character,  disturbance  of  memory,  confusion,  in- 
tellectual weakness,  irritability,  attacks  of  excitement  or  depres- 
sion, etc.  If  the  third  frontal  convolution  or  its  projection 
pathways  in  the  left  hemisphere  in  right-handed  individuals, 
and  the  right  hemisphere  in  left-handed  individuals,  is  involved, 
there  occurs  a  disturbance  of  speech  known  as  aphasia.  In 
this  condition  the  individual  knows  what  he  wishes  to  say  and 
recognizes  objects,  but  is  unable  to  express  himself  or  to  call 
objects  by  their  names.  In  some  instances  the  patient  may  be 
able  to  utter  a  few  meaningless  sounds  or  even  words. 

If  the  precentral  convolution  or  its  projection  pathways  are 
involved,  disturbance  of  motility  occurs.  According  to  the 
severity  of  the  lesion,  there  occurs  either  a  weakness  or  a  paral- 
ysis; this  manifests  itself  as  a  disturbance  of  voluntary  move- 
ments. The  more  highly  specialized  and  the  most  difficult 
acquired  movements  are  those  which  are  always  most  seriously 
affected.  If  the  lesion  is  on  the  cortex,  the  paralysis  or  weakness 
may  be  of  very  limited  extent,  involving  the  facial  movements 
or  those  of  an  arm  or  a  leg;  or,  if  more  extensive,  perhaps  the 
face,  or  the  face  and  arm,  or  the  arm  and  the  leg,  etc.,  may  be 
^     affected. 

An  apoplectic  seizure  due  to  a  surface  lesion  in  this  region 


RUPTURE    OR    OCCLUSION    OF    CEREBRAL    ARTERIES      393 


may  be  ushered  in  by  convulsive  movements  that  are  at  first 
limited  in  extent,  but  later  may  become  extensive  and  be  followed 
by  paralysis,  etc.  If  the  lesion  is  beneath  the  surface,  that  is, 
in  the  projection  paths  from  the  precentral  convolution,  the 
paralysis  or  weakness  is  generally  much  more  extensive,  particu- 
larly if  the  lesion  involves  the  anterior  two-thirds  of  the  posterior 
limb  of  the  internal  capsule.  In  this  position  a  very  small 
lesion  brings  about  a  paralysis  of  the  arm,  leg,  face,  and  trunk 
of  one  side  of  the  body.     This  condition  is  known  as  hemiplegia. 


%. 


r,  'S 


Fig.    140. — Facial  paralysis   follomng  apoplectic   stroke  in  patient   with 

complete  aphasia. 


Immediately  after  an  attack  there  is  generally  complete  relaxa- 
tion of  all  the  muscles.  Within  a  few  hours,  even  if  the  patient 
does  not  move  the  non-paralyzed  side,  a  greater  relaxation  on 
one  side  is  observed,  together  with  a  drawing  of  the  face,  an 
elevation  of  the  corner  of  the  mouth  on  the  non-paralyzed 
side  (Fig.  140),  with  dribbling  of  saliva  on  the  paralyzed  side, 
difficulty  in  swallowing,  etc.  Within  a  short  time  an  increased 
tonicity  and  a  tendency  to  contractures  of  the  muscles  on  the 
paralyzed  side  are  noticed.  This  is  more  marked  in  cases  in 
which  the  lesions  are  subcortical  than  in  those  in  which  the 


394 


MANUAL   OF   NERVOUS   DISEASES 


cortex  is  affected.  After  an  attack  the  head  and  eyes  are  usu- 
ally turned  away  from  the  paralyzed  side;  that  is,  they  deviate 
toward  the  site  of  the  lesion. 

During    the    comatose    or    semiconscious    state    automatic 
instinctive  movements  may  occur  on  the  non-paralyzed  side. 

Convulsive  movements  occurring 
after  an  apoplectic  seizure  usu- 
ally indicate  rupture  of  a  vessel 
and  hemorrhage  into  the  ventricles. 
Apoplectic  seizures  that  are  ushered 
in  with  sudden,  severe,  generalized 
convulsive  attacks  generally  indi- 
cate a  primary  involvement  of  the 
ventricles.  If  recovery  is  to  take 
place,  within  a  short  time  after 
an  apoplectic  seizure  there  is  a 
gradual  return  of  some  of  the  move- 
ments of  the  paralyzed  side;  the 
first  to  occur  are  the  grosser  move- 
ments of  the  leg  and  arms.  In 
some  there  is  almost  complete  re- 
covery, even  of  the  finer  move- 
ments of  the  fingers  and  toes;  in 
most  cases  in  which  recovery  does 
take  place  there  remains  some  clum- 
siness in  affecting  the  finer  move- 
ments of  the  fingers  and  hands. 

The  gait  of  those  who  have  sus- 
tained an  attack  of  hemiplegia  and 
who  still  live  is  more  or  less 
characteristic:  the  patient  walks 
with  the  trunk  thrown  forward ;  the 
shoulder  on  the  paralyzed  side  is 
lower  than  that  on  the  non-para- 
lyzed side;  the  arm  is  adducted  on 
the  trunk;  the  forearm  is  flexed  on  the  arm;  the  hand  is  pro- 
nated  and  flexed  at  the  wrist,  and  the  fingers  are  flexed 
(Fig.  141). 


Fig.    141. — Posture    in    hemi 
plegia. 


RUPTURE    OR   OCCLUSION    OF    CEREBRAL    ARTERIES      395 

The  paralyzed  leg  is  held  stiff.  The  foot  may  be  turned 
outward  or  inward — usually  outward.  When  the  patient 
walks,  he  does  not  bend  the  knee,  but  swings  the  foot  outward 
in  the  arc  of  a  circle,  usually  drawing  the  Imll  and  the  inner 
aspect  of  the  foot  along  the  ground.  The  efforts  made  when 
walking  are  frequently  attended  by  an  increase  in  the  con- 
tracture of  the  arm,  and  sometimes  of  the  face.  Not  infre- 
quently, after  the  occurrence  of  a  hemiplegic  attack,  associ- 
ated and  athetoid  movements  in  the  paralyzed  limbs  take 
place. 

The  Reflexes. — Immediately  after  an  apoplectic  seizure,  if 
the  patient  is  unconscious,  the  reflexes  are  usually  lost,  there  is 
a  loss  of  the  pupillary  reaction  to  light,  and  there  is  relaxation 
of  the  vesical  and  rectal  sphincters,  with  an  emptying  of  the 
contents  of  bladder  and  rectum.  Within  a  few^  hours,  or  at 
the  most  days,  if  a  fatal  termination  is  not  imminent,  there  is 
usually  a  return  of  the  tendon  reflexes,  which  later  become 
markedly  increased.  Ankle-clonus  and  the  Babinski  sign  often 
occur  on  the  side  of  the  paralysis  within  a  few  days  after  an 
attack.  In  the  less  serious  attacks,  in  which  there  has  not  been 
so  much  destruction  of  tissue,  the  deep  reflexes  return  rapidly 
and  soon  become  increased,  but  the  skin  reflexes  on  the  paralyzed 
side  are  permanently  lost.  The  pupillary  reflexes  gradually 
return  as  the  unconsciousness  begins  to  subside.  With  the 
return  of  the  tendon  reflexes  there  is  also  a  return  of  the  reflex 
control  of  the  rectum  and  bladder.  As  there  is  usually  retention 
of  urine  and  feces,  it  may  be  necessary  to  resort  to  catheter- 
ization to  empty  the  bladder,  and  to  enema  to  clear  the  rectum. 
At  other  times  there  may  be  -involuntary  evacuation  of  bowel 
and  bladder  contents. 

If  the  lesion  involves  the  anterior  part  of  the  parietal  lobe, 
transient  motor  symptoms  will  occur,  and  if  the  lesion  is  on  the 
surface  of  the  brain,  paresthesia  may  occur  upon  the  opposite 
side,  to  be  follow^ed  later  by  anesthesia,  which  usually  almost 
completely  disappears.  If  the  lesion  is  in  the  projection  paths 
from  the  parietal  lobe,  there  also  occurs  paresthesia,  followed 
by  anesthesia,  and  there  are  generally  added  to  these  dis- 
turbances of    intellect,  due  to  destruction  of  the  association 


396  MANUAL  OF  NERVOUS  DISEASES 

pathways.  The  sensory  disturbances  are  not  permanent  as  a 
rule. 

If  the  lesion  affects  the  angular  and  supramarginal  gyrus, 
astereognosis  occurs.  If  the  lesion  involves  the  temporal  lobe, 
there  may  be  disturbance  of  smell  and  of  hearing;  if  the  lesion 
involves  the  lateral  aspect  of  the  occipital  lobe,  alexia  occurs; 
if  the  lesion  involves  the  median  aspect  of  the  occipital  lobe  or 
its  projection  pathways,  bilateral  hemianopsia  occurs,  with 
retention  of  the  pupillary  reflex.  In  those  cases  in  which  the 
lesion  occurs  in  the  cerebellum, — and  these  are  certainly  un- 
common,— there  may  or  may  not  be  a  disturbance  of  conscious- 
ness. If  the  consciousness  is  not  disturbed,  or  if  lost,  after 
it  has  been  recovered,  the  patient  experiences  intense  vertigo, 
double  vision,  nystagmus,  attacks  of  vomiting,  and  severe 
prostration.  There  is  usually  marked  incoordination  of  move- 
ment, and  the  gait  is  staggering.  The  patient  may  recover 
from  all  these  symptoms  or  the  vertigo  and  incoordination  may 
remain. 

If  the  lesion  involves  the  crura,  pons,  or  medulla,  a  character- 
istic symptom-complex  presents  itself:  if  the  lesion  affects  the 
crura,  involving  only  one  side,  there  occurs  a  paralysis  of  the 
muscles  supplied  by  the  third  and  fourth  nerves  on  the  side  of 
the  lesion,  with  a  spastic  paralysis  on  the  opposite  side  of  the 
body,  including  the  face,  tongue,  upper  extremity,  trunk,  and 
leg.  Lesions  in  the  pons  give  rise  to  great  restlessness  and 
paralysis  of  one  or  both  sides  of  the  body;  if  the  lesion  involves 
only  one  side  of  the  pons,  there  will  be  a  paralysis  of  the  fifth 
nerve  on  one  side,  with  paralysis  on  the  opposite  side  of  the 
body.  In  pontile  lesions  the  pupils  are  usually  contracted, 
and  the  patient,  if  not  unconscious,  is  very  emotional.  If  the 
lesion  involves  the  lower  part  of  the  pons  or  the  upper  part  of 
the  medulla,  there  occurs  a  paralysis  of  the  muscles  supplied 
by  the  sixth  and  seventh  nerves  on  the  side  of  the  lesion  and 
the  opposite  side  of  the  body.  If  the  lesion  in  this  region 
involves  both  sides  of  the  brain-stem,  there  may  be  a  paralysis 
of  the  muscles  supplied  by  the  sixth  and  seventh  nerves  on  both 
sides,  with  or  without  paralysis  on  one  or  both  sides  of  the  body 
below. 


RUPTURE    OR   OCCLUSION    OF    CEREBRAL   ARTERIES      397 

Vascular  lesions  below  the  upper  part  of  the  medulla,  if  they 
are  at  all  extensive,  cause  death  more  or  less  promptly.  Very 
small  lesions  may  exist,  and  these  may  give  rise  to  symptoms 
pointing  to  involvement  of  the  nuclei  of  the  twelfth,  ninth,  or 
tenth  nerves,  resulting  in  paralysis  of  the  tongue,  and  difficulty 
in  swallowing  and  in  talking.  If  the  lesion  affecting  the  brain- 
stem involves  the  deeper  structures,  there  may  be  no  paralysis, 
but  disturbance  of  sensation  and  of  coordination  may  accom- 
pany the  cranial  nerve  paralysis.  Paralysis  of  the  cranial 
nerves  that  occurs  directly  as  the  result  of  the  lesion  in  the  brain 
stem  is  ahvays  of  the  flaccid  type,  whereas  paralysis  of  the 
parts  of  the  body  below  the  lesion  is  of  the  spastic  type. 

Course. — Diseased  conditions  of  the  brain  due  to  vascular 
disturbance  may  be  acute  in  onset,  but  usually  occur  only  after 
manifestations  of  a  disturbed  circulation  have  existed  for  a 
considerable  time.  Symptoms  pointing  to  vascular  disease  of 
the  brain  may  exist  for  many  years,  or,  on  the  other  hand, 
rupture  or  occlusion  of  a  vessel  may  take  place  without  any  of 
the  premonitory  symptoms.  When  an  apoplectic  attack  has 
occurred,  the  patient  may  or  may  not  become  unconscious, — the 
period  of  unconsciousness  may  last  from  a  few  minutes  to  several 
days.  The  patient  may  die  within  a  few  hours  after  the  attack, 
or  may  gradually  emerge  from  the  comatose  state.  If  the  patient 
has  been  unconscious  and  emerges  from  this  state,  there  is 
usually  a  period  of  mental  heaviness  and  confusion  lasting 
several  days  or  weeks;  the  patient  may  die  during  this  time  or 
gradually  regain  consciousness. 

As  soon  as  consciousness  recurs,  or  in  those  patients  who  have 
not  been  unconscious,  the  breathing  again  becomes  normal,  the 
ability  to  swallow  is  regained,  and  control  of  rectal  and  vesical 
reflexes  is  reestablished.  Those  patients  who  are  not  aphasic 
begin  to  express  their  desires  by  speech,  at  first  very  indistinctly, 
but  within  a  few^  days  fairly  well.  The  paralysis,  which  at 
first  completely  affects  all  movements  of  one  side,  may  gradually 
improve,  the  grosser  movements  of  the  extremities  being  the 
first  to  return.  In  some  cases  the  paralysis  may  disappear 
almost  entirely,  whereas  in  other  cases  very  little  improvement 
may  be  noticed. 


398  MANUAL   OF   NERVOUS   DISEASES 

Contractures,  associated,  automatic,  or  athetoid  movements 
may  appear. 

Prognosis. — The  prognosis  in  apoplectic  attacks  is  always 
grave,  owing  to  the  fact  that  not  alone  is  the  attack  itself  a 
serious  occurrence,  but  because  of  the  tendency  for  subsequent 
attacks  to  occur.  Those  cases  ushered  in  with  violent  con- 
vulsive seizures,  followed  by  unconsciousness,  generally  die 
within  three  or  four  days.  In  those  patients  who  remain  un- 
conscious for  over  four  days,  and  in  whom  there  is  some  elevation 
of  temperature  with  a  high  blood-pressure,  the  outlook  is  very 
serious,  as  death  from  pulmonary  involvement  or  exhaustion 
is  very  prone  to  ensue.  When  the  symptoms  point  to  extensive 
involvement  of  the  brain-stem  the  patient  almost  always 
dies  within  three  days.  In  those  cases  in  which  there  is  less 
disturbance  of  consciousness,  or  in  those  patients  who  rapidly 
regain  consciousness,  and  the  examination  of  the  heart  and 
lungs  does  not  lead  to  apprehension,  recovery  almost  always 
ensues.  Subsequent  attacks  may  occur — sometimes  within 
twenty-four  hours.  Following  a  seizure  some  individuals  re- 
main very  emotional,  weeping  or  laughing  without  adequate 
cause;  others  show  disturbance  of  memory,  marked  irritability, 
mental  confusion,  etc. 

Recovery  of  the  motor  functions  upon  the  affected  side  may 
take  place  in  whole  or  in  part:  usually  the  face  recovers  almost 
entirely,  and  very  little  deviation  of  the  tongue  remains;  volun- 
tary power  of  the  upper  and  lower  extremities,  particularly  of 
the  finer  movements,  may,  however,  be  permanently  lost;  as 
a  rule,  less  voluntary  control  is  recovered  in  the  arm  than  in  the 
leg. 

The  paralysis  of  the  affected  parts  is  of  a  spastic  nature,  con- 
tractures and  abnormal  movements  developing  in  some  cases, 
whereas  in  others  voluntary  power  may  be  regained  to  a  con- 
siderable extent,  disturbance  of  sensation  being  the  only  perma- 
nent symptom.     Hemianopsia  is  usually  permanent. 

Diagnosis. — The  diagnosis  of  vascular  disease  of  the  brain  is 
made  from  the  evidence  of  general  cardiovascular  disease  and 
from  the  occurrence  of  symptoms  pointing  toward  interference 
with  the  cerebral  circulation,  such  as  paresthesia,  limited  to 


RUPTURE    OR   OCCLUSION    OF    CEREBRAL   ARTERIES      399 

one  arm  or  one  side  of  the  body,  in  the  absence  of  local  causes; 
vertigo,  headache,  disturbances  of  sleep,  disorders  of  speech, 
emotional  disturbances,  transient  attacks  of  weakness  limited 
to  one  side  of  the  body,  etc.  If  an  apoplectic  attack  occurs, 
it  must  be  differentiated  from  an  attack  of  syncope:  in  the  latter 
condition  the  patient's  face  is  usually  pale,  the  respiration  is 
shallow,  the  cardiac  sounds  are  distant  and  weak,  the  pupils 
are  equally  dilated,  and  there  is  retention  of  the  knee  reflexes, 
with  rapid  recovery  following  the  administration  of  stimulants. 
From  an  epileptic  attack  an  apoplectic  seizure  is  distinguished 
by  the  fact  that  in  the  former  there  is  generally  a  history  and 
local  evidence  of  previous  epileptic  seizures,  such  as  scars  upon 
the  tongue  or  upon  the  person;  moreover,  epileptic  seizures 
occur  more  frequently  in  }'outh,  whereas  apoplectic  attacks 
occur  later  in  life.  In  epilepsy  signs  of  cardiovascular  dis- 
ease are  generally  absent,  whereas  in  apoplexy  they  are 
usually  present.  The  coma  following  an  epileptic  seizure  is 
short,  and  when  the  patient  has  regained  consciousness  there 
is  an  absence  of  symptoms  pointing  to  a  lesion  of  the  brain. 

An  apoplectic  attack  is  distinguished  from  a  comatose  state 
the  result  of  intoxication  from  alcohol,  opium,  etc.,  by  the  fact 
that  in  the  latter  the  individual  can  usually  be  roused;  there 
is  also  an  absence  of  symptoms  pointing  to  local  brain  involve- 
ment, and  practically  never  is  there  a  loss  of  the  pupillary 
reflexes.  Owing  to  the  fact  that  apoplectic  attacks  ma}'  occur 
in  persons  who  are  under  the  influence  of  alcohol  it  is  important 
that  in  examining  these  individuals  search  be  made  for  symptoms 
of  localized  brain  involvement.  It  is  at  times  very  difficult  to 
distinguish  betw^een  an  apoplectic  attack  and  uremic  coma. 
When  no  history  is  obtainable,  it  is  only  by  the  presence  of 
symptoms  pointing  to  localized  involvement  of  the  brain  that 
one  is  enabled  to  distinguish  between  a  vascular  disturbance 
of  the  brain  and  a  toxic  condition.  It  must  constantly  be 
borne  in  mmd  that  apoplectic  attacks  are  of  somewhat  common 
occurrence  in  persons  who  are  affected  with  a  chronic  inter- 
stitial nephritis.  It  is  important,  but  at  times  difficult  or 
almost  impossible,  to  differentiate  between  apoplectic  attacks 


4oo 


MANUAL  OF  NERVOUS  DISEASES 


caused  by  hemorrhage,  thrombosis,  or  embolus.    The  following 
table  is  useful  in  making  the  differentiation : 


Hemorrhage. 

Thrombosis. 

Embolus. 

Age: 

Occurs  most  frequently 

Occurs  most  frequently 

Occurs  at  any  age. 

before      the     seventh 

in  old  age,   in  young 

year    and    after    the 

adults  who  have  had 

fortieth  year. 

syphilis,    or    in    indi- 
viduals who  have  be- 
come very  much  weak- 
ened as  the  result  of 
some     prolonged     ex- 
hausting disease. 

Predisposing 

Heredity    is    a    marked 

Heredity  an  uncommon 

Heredity     has     no     in- 

causes: 

cause. 

cause. 

fluence. 

Arteriosclerosis  with  high 

Arteriosclerosis  with  low 

Endocarditis,    calcareous 

blood-pressure. 

blood-pressure. 

degeneration,  with 
roughened  vascular 
walls,  etc. 

Exciting 

Excitement,      overexer- 

Sleep,    diseased     condi- 

Excitement,     overexer- 

causes: 

tion,  trauma,  convul- 

tions   bringing    about 

tion,  injury,  infectious 

sions,  etc. 

a  low  blood-pressure. 

diseases,     convulsions, 

depression,     extensive 

etc. 

hemorrhage,  etc. 

Onset: 

Prodromal       symptoms 

Prodromal        symptoms 

Prodromal        symptoms 

may  or  may  not  exist. 

common. 

usually  do  not  exist. 

Attacks     usually     very 

More    or    less    gradual, 

Attack  sudden. 

sudden. 

frequently  taking  sev- 
eral hours  for  attack 
to    attain    its    maxi- 
mum degree. 

Appearance: 

Face  usually  congested; 

Face  usually  pale. 

Face  may  be  either  con- 

conjunctivae  injected; 

gested  or  pale. 

lips  cyanotic. 

Coma: 

Common;    usually    sud- 

Uncommon; more  grad- 

Uncommon, but  when  it 

den  and  complete. 

ual  in  onset  and  usu- 

occurs, is  of  sudden  on- 

' 

ally  not  well  marked. 

set,  and  usually  rap- 
idly recovered  from. 

Respiration: 

Usually    sterterous,     ir- 

P'requently   no    disturb- 

Generally    no     disturb- 

regular,  or   of  the 

ance;  irregular. 

ance. 

Cheyne-Stokes 

variety. 

Pulse: 

Usually   slow,   full,   and 

Usually  weak,  soft,  and 

May   be   either  slow   or 

bounding. 

rapid. 

rapid,  but  is  usually 
full  and  well  sustained. 

Distribution 

Hemiplegia  usually  com- 

More  limited,    but   fre- 

May be  limited  or  exten- 

of motor 

plete,  followed  by  im- 

quently becomes  more 

sive,  often  with  rapid 

symptoms : 

provement. 

extensive. 

improvement. 

Temperature: 

At    first     reduced    and 

No  changes. 

No  changes. 

later  elevated. 

, 

Eyes: 

Pupils  .unequal;    pupils 

Equal.       React,     unless 

Equal.        React      unless 

fail  to  react  to  light. 

coma  is  present.   Usu- 

coma is  present.    Usu- 

Eyes  generally 

ally  no  deviation. 

ally  no  deviation. 

turned  away  from  the 

side  of  the  paralysis. 

Blood: 

A  rapid  increase  in  the 
leukocytes. 

No  increase. 

No  increase. 

Vasomotor 

Edema,    cyanosis,    and 

Uncommon. 

Uncommon. 

symptoms: 

increased        sweating 
common. 

Urine: 

Frequently       increased; 

No    changes    over    pre- 

No   changes    over    pre- 

may contain  albumin 

vious     condition     no- 

vious    condition     no- 

and sugar. 

ticed. 

ticed. 

RUPTURE   OR  OCCLUSION   OF    CEREBRAL   ARTERIES      40I 

Treatment. — The  treatment  of  diseases  of  the  brain  due  to 
disturbance  of  the  cerebral  circulation,  to  be  efficient,  must  be 
directed  toward  the  prevention  and  more  or  less  permanent 
relief  of  the  underlying  cardiovascular  diseases.  Proper  at- 
tention must  be  given  to  the  diet,  and  alcoholic  beverages 
avoided.  The  use  of  tobacco,  coffee,  etc.,  is  to  be  limited. 
The  bowels  should  be  kept  well  open,  and  an  adequate  amount 
of  water  should  be  taken.  A  moderate  amount  of  exercise, 
such  as  walking,  horseback  riding,  golf,  etc.,  should  be  indulged 
in,  and  all  overexertion  and  excitement  should  be  avoided. 
Very  hot  or  very  cold  baths  are  not  to  be  indulged  in,  but 
tepid  or  cool  sponges  are  to  be  recommended.  All  acute  disease 
should  receive  prompt  and  careful  attention.  Overeating, 
exposure  to  inclement  weather, — either  too  hot  or  too  cold, — 
overwork,  etc.,  are  all  harmful.  If  the  patient  is  debilitated, 
anemic,  and  weak,  rest,  together  with  proper  food  and  tonics, 
is  to  be  prescribed.  Such  diseases  as  syphilis  and  nephritis 
should  receive  the  proper  treatment.  In  all  cases  in  which 
arteriosclerosis  is  present  the  administration  of  potassium 
iodid  in  5-grain  doses,  given  at  intervals  over  a  prolonged 
period,  is  of  benefit,  provided  it  does  not  disagree  with  the 
patient. 

The  treatment  of  an  apoplectic  attack  is  dependent  upon  the 
cause.  The  patient  should  be  placed  in  a  comfortable  reclining 
position,  with  the  clothing  loosened,  and,  above  all,  be  kept 
quiet.  He  should  be  moved  as  little  as  possible.  In  my  ex- 
perience the  pulse-rate  and  the  blood-pressure  are  usually  the 
safest  guides  as  to  the  administration  of  drugs  and  as  to  further 
treatment:  in  those  cases  in  which  the  blood-pressure  is  high, 
that  is,  from  160  to  200  or  more,  and  in  which  the  pulse  ranges 
from  60  to  no,  it  is  advisable  to  place  ice-caps  upon  the  head 
and  to  administer  a  rapidly  acting  purgative,  such  as  croton 
oil.  If  the  patient  is  very  restless,  small  doses  of  morphin, 
or  if  he  is  not  unconscious,  sodium  bromid,  may  be  given.  The 
pulse-rate  and  the  blood-pressure  must  be  carefully  watched: 
if  the  pulse  becomes  slower  and  the  blood-pressure  rises,  this 
is  an  indication  of  increased  intracranial  pressure,  and  it  may 
be  necessary  to  open  the  cranium  in  order  to  save  the  patient's 
26 


402  MANUAL   OF   NERVOUS   DISEASES 

life.  This  should,  of  course,  be  promptly  done  if  a  cortical 
hemorrhage  is  suspected.  In  those  cases  in  which  it  is  believed 
that  the  hemorrhage  is  deeper  in  the  brain  substance  an  operation 
may  save  the  patient's  life,  but  it  cannot,  of  course,  restore  the 
destroyed  cerebral  tissue.  In  those  cases  in  which  the  face  is 
cyanosed  and  flushed,  the  pulse  slow,  full  and  bounding,  and 
the  blood-pressure  high,  if  the  patient  is  not  promptly  benefited 
by  free  purgation  and  the  application  of  ice-caps  to  the  .head, 
venesection  may  prove  useful.  If  the  patient  is  unconscious, 
care  should  be  taken  that  he  is  placed  in  such  a  position  as  to 
render  his  breathing  as  easy  as  possible.  He  should  be  turned 
carefully  from  side  to  side,  always  permitting  him  to  rest  longest 
on  the  non-paralyzed  side.  Attention  should  be  given  to  the 
bowels  and  bladder,  and  care  should  be  exercised  to  prevent 
the  development  of  bed-sores.  Food  should  be  withheld.  The 
mouth  should  be  kept  clean,  and  small  quantities  of  water 
should  be  frequently  administered. 

In  those  cases  in  which  the  face  is  pale,  the  blood-pressure 
low,  and  the  pulse  more  or  less  rapid,  the  patient  should  be 
placed  in  bed,  with  his  head  slightly,  if  at  all,  elevated.  His 
position  should  be  frequently  but  carefully  changed  from  side 
to  side,  and  cardiac  stimulants  should  be  administered.  These 
cases  frequently  do  well  on  brandy  given  in  small  doses,  strych- 
nin, aromatic  spirits  of  ammonia,  camphor,  etc.  Strophanthin 
hypodermically,  followed  by  the  digitalis  preparations,  is  of 
great  value  at  times  in  those  cases  in  which  the  cardiac  muscle 
is  responsible  for  the  disturbed  cerebral  circulation.  As  soon 
as  possible  the  patient  should  receive  a  nutritious  but  light 
diet,  and  tonics  be  administered.  When  the  exciting  cause  is 
believed  to  be  an  embolus,  providing  there  are  no  cardiac 
contraindications,  nitroglycerin  and  strychnin  are  to  be  given, 
so  that  the  embolus  will  be  pushed  as  far  forward  as  possible 
into  the  occluded  vessel. 

The  less  severe  cases,  in  which  there  is  no  disturbance  of 
consciousness,  should  receive  the  same  careful  attention  that 
is  given  the  most  severe  cases. 

The  diet  should  be  regulated,  and  fluids  given  in  abundance. 
The  position  of  the  patient  should  be  changed  from  time  to 


THROMBOSIS    OF    THE    CEREBRAL    SINUSES    AND    VEINS      403 

time,  and  ho  should  be  made  as  comfortable  as  possible.  The 
bowels  are  to  be  regulated,  and  proper  attention  given  to  the 
skin. 

At  the  end  of  ten  days  or  two  weeks  in  the  mild  cases,  and  in 
from  four  to  six  or  eight  weeks  in  the  more  severe  cases,  the 
patient  may  be  allowed  to  sit  in  a  chair,  and  later  be  permitted 
to  make  attempts  at  standing.  While  he  is  making  these  at- 
tempts at  standing  and  sitting  the  patient  should  be  supported, 
and  not  allowed  to  overexert  himself. 

About  two  weeks  after  an  attack  massage  of  the  affected 
parts  should  be  begun,  passive  movements  carried  out,  and  the 
faradic  current  applied.  By  means  of  the  electric  current,  mas- 
sage, and  passive  movements  contractures. should  be  prevented 
as  far  as  possible.  Gradually,  as  the  voluntary  movements 
return,  they  should  be  encouraged.  In  those  cases  in  which 
cortical  hemorrhage  is  diagnosed,  prompt  surgical  interv^ention 
is  justifiable.  Some  cases  of  subcortical  hemorrhage  in  which 
there  is  evidence  pointing  to  a  fatal  termination  may  be  saved 
temporarily  at  least  by  surgical  intervention. 

In  those  patients  who  suffer  with  sensory  disturbances 
improvement  usually  follow^s  the  application  of  the  faradic 
current.  Aphasia  is  to  be  treated  by  reeducation;  the  mental 
and  emotional  symptoms  are  generally  not  benefited  by  treat- 
ment, but  these  patients  should  have  agreeable,  pleasant,  and 
quiet  surroundings,  and  be  spared  all  excitement  and  mental 
distress. 

THROMBOSIS   OF    THE    CEREBRAL    SINUSES    AND 

VEINS 

Etiology. — Thrombosis  of  the  cerebral  sinuses  or  veins  may 
occur  as  a  primary  affection  in  individuals  who  are  markedly 
debilitated  as  the  result  of  prolonged  exhausting  disease,  in 
general  cachectic  conditions,  cardiac  weakness,  after  very 
severe  diarrhea,  tuberculosis,  malignant  growths,  etc.  This 
condition  occurs  more  frequently  in  very  young  or  very  old 
individuals.  A  primary  thrombosis  may  also  occur  as  the 
result  of  pressure  on  veins  or  a  sinus  resulting  from  a  tumor  or 


404  MANUAL  OF  NERVOUS  DISEASES 

an  injury.  It  may  also  occur  as  a  concomitant  of  inflammation 
of  the  venous  walls  due  to  extension  of  an  inflammatory  process, 
or  may  be  secondary  to  a  septic  process  elsewhere.  In  these 
cases  the  thrombus,  if  infected,  contains  bacteria.  The  com- 
monest causes  of  infective  sinus  thrombosis  are  otitis  media, 
chronic  nasal  or  accessory  nasal  sinus  disease,  septic  traumatic 
conditions  of  the  face,  scalp,  and  cranial  and  facial  bones, 
erysipelas,  carbuncles  or  abscesses,  meningitis,  etc.  Probably 
the  most  frequent  cause  of  infected  sinus  thrombosis  is  otitis 
media  or  mastoiditis. 

Pathology. — A  thrombus  may  be  confined  to  one  sinus,  or 
to  even  a  part  of  it,  or,  by  gradual  extension,  several  sinuses 
may  be  invaded.  When  the  entire  lumen  of  a  cortical  vein  is 
occluded,  the  portion  of  the  brain  drained  by  this  vein  is  gener- 
ally the  seat  of  edema  and  softening.  The  lumen  of  the  vein 
or  sinus  is  usually  occluded  by  a  soft  clot,  which  is  adherent 
to  its  walls.  In  those  cases  that  have  existed  for  some  time  the 
clot  may  undergo  organization.  When  the  thrombus  becomes 
infected,  the  clot  usually  breaks  down,  the  vascular  walls 
become  rough,  and  there  is  an  extension  of  the  infection  into 
the  immediate  neighborhood.  The  clot  may  extend,  and  the 
internal  jugular  vein  is  often  invaded.  If  the  particles  are 
carried  from  the  infected  clot,  a  general  pyemic  condition  may 
result,  the  septic  emboli  being  carried  to  the  various  organs  of 
the  body. 

As  the  result  of  occlusion  of  the  sinuses  there  occurs  a  con- 
gestion of  the  brain  in  the  areas  drained  by  the  sinus,  and 
frequently  there  is  red  softening  in  these  areas. 

Symptoms. — The  symptoms  of  a  primary  non-septic  throm- 
bosis are  those  of  a  localized  edema  and  interference  or  loss  of 
function  of  a  portion  of  the  brain.  This  condition  usually 
follows  a  prolonged  exhausting  illness.  The  superior  longi- 
tudinal sinus  is  the  one  that  is  most  frequently  affected.  When 
this  sinus  is  occluded,  there  generally  results  edema  of  the  scalp 
and  epistaxis,  and  frequently  convulsions,  which  may  be  lim- 
ited in  extent,  and  be  accompanied  by  weakness  or  paralysis  of 
the  lower  extremities. 

The  presence  of  a  primary  thrombosis  may  be  suspected  in 


THROMBOSIS    OF    THE    CEREBRAL    SINUSES    AND    VEINS      405 

individuals  in  whom  an  exhausting  disease  exists,  and  when 
an  edema  of  the  face  or  scalp  is  followed  by  convulsions,  symp- 
toms of  meningeal  irritation,  weakness,  or  paralysis. 

The  symptoms  of  an  infective  thrombosis  are  of  two  varieties, 
— the  systemic  and  the  local.  The  systemic  symptoms  are 
those  of  a  general  systemic  infection;  they  include:  Headache, 
which  may  be  very  intense;  gastro-intestinal  disturbances, 
such  as  vomiting  and  loss  of  appetite;  marked  elevation  alternat- 
ing with  depression  of  temperature;  a  pulse  usually  rapid  and 
small;  chills,  profuse  perspiration,  leukocytosis,  a  dry,  coated 
tongue,  etc.  To  these  symptoms  may  be  added  others  pointing 
toward  involvement  of  any  of  the  organs  of  the  body.  If 
septic  emboli  are  carried  to  the  lungs,  symptoms  occur  pointing 
to  involvement  of  these  organs;  if  the  abdominal  organs  are 
involved,  the  symptoms  point  toward  the  viscera.  In  some 
cases  there  may  be  symptoms  pointing  toward  meningeal  ir- 
ritation, and  a  diffuse  leptomeningitis  may  occur. 

The  localized  symptoms  are  due  to  local  circulatory  disturb- 
ances and  to  a  localized  involvement  of  the  brain.  These 
symptoms  depend  upon  the  site  of  the  pathologic  lesion. 

When  the  cavernous  sinus  is  involved,  the  orbital  contents 
become  edematous,  and  exophthalmos,  sometimes  bilateral, 
occurs.  The  eyelids  of  one  or  both  sides  are  swollen,  the  edema 
sometimes  extending  to  the  side  of  the  face.  The  optic  disc 
is  congested,  and  the  retinal  veins  are  distended.  If  pressure 
is  exerted  on  the  third,  fourth,  and  skth  nerv^es,  evidence  of 
interference  with  their  functions  exists.  The  involvement  of 
this  sinus  is  usually  secondary  to  a  purulent  disease  of  the  orbit, 
sphenoidal  sinuses,  erysipelas  of  the  face,  ulcerative  conditions 
of  the  throat  and  mouth,  and  extension  for^^ard  of  septic 
conditions  of  the  lateral  and  petrosal  sinuses. 

Local  Symptoms  of  Infective  Thrombosis  of  the  Longitudinal 
Sinus. — This  sinus  is  very  rarely  affected.  The  involvement 
may  be  secondary  to  purulent  diseases  of  the  nose,  erysipelas 
of  the  scalp,  purulent  conditions  of  the  cranial  bones  of  the 
vertex  of  the  skull,  etc.  The  local  evidences  of  occlusion  are 
edema  of  the  scalp,  nose-bleed,  and  sometimes  s\Tnptoms 
pointing  toward  an  edema  of  the  vertical  portion  of  the  brain. 


4o6  MANUAL   OF   NERVOUS   DISEASES 

Infective  Lateral  Sinus  Thrombosis. — The  lateral  sinus  is  the 
one  most  frequently  affected.  The  most  common  cause  of  an 
infective  disease  of  this  sinus  is  a  septic  condition  of  the  middle 
ear.  It  may  also  arise  secondary  to  disease  of  the  throat, 
the  infection  traveling  by  way  of  the  Eustachian  tubes,  from 
fracture  of  the  base  of  the  skull,  from  extension  of  septic  throm- 
bosis in  other  sinuses,  and  it  may  also  be  secondary  to  infections 
about  the  occipital  and  mastoid  regions. 

Local  Symptoms. — As  a  rule  there  is  a  circumscribed  edema 
over  the  mastoid.  Sometimes  a  brawny  hardness  and  edema 
in  the  superior  cervical  triangle  occurs,  and  should  the  inflam- 
mation extend  into  the  internal  jugular,  which  it  frequently 
does,  local  tenderness  is  found  over  the  upper  portion  of  this 
vessel.  At  times  the  internal  jugular  vein  may  be  palpated 
as  a  firm,  cord-like  structure.  The  head  is  usually  inclined  to 
the  affected  side  and  the  lymphatic  glands  in  the  neck  are 
frequently  enlarged.  In  some  cases  pressure  is  exerted  in  the 
jugular  foramen  upon  the  pneumogastric,  spinal  accessory,  and 
glossopharyngeal  nerves,  producing  respiratory,  laryngeal,  and 
cardiac  disturbances,  difficulty  in  swallowing,  and  weakness 
or  paralysis  of  the  sternomastoid  and  trapezius  muscles.  To 
these  symptoms  are  generally  added  evidences  of  disturbed 
cerebral  circulation  and  disordered  cerebral  functions.  Gen- 
erally headache  and  vomiting  are  marked,  and  there  is  a  tendency 
toward  somnolence,  which  may  deepen  into  coma.  Delirium 
often  occurs  as  an  early  symptom.  Later  the  infection  may 
extend  into  the  temporosphenoidal  lobe,  forming  an  abscess  in 
this  region,  or  it  may  extend  inward  into  the  cerebellum,  where 
it  gives  rise  to  an  abscess,  or  the  dura  may  become  affected 
and  local  septic  meningitis  develop. 

Course. — A  primary  thrombosis  of  the  cerebral  sinus  is  al- 
ways preceded  by  some  disease  that  brings  about  a  marked 
lowering  of  the  vitality  of  the  individual  and  a  slowing  of  the 
blood-current.  More  or  less  suddenly  symptoms  pointing  to 
occlusion  of  the  cerebral  sinus  or  cerebral  veins  appear.  A 
secondary  or  septic  thrombosis  is  likewise  always  preceded  by 
some  disease  or  conditian  that  causes  the  formation  of  an  in- 
fected clot  in  a  cerebral  sinus  or  a  cerebral  vein.     The  rapidity 


THROMBOSIS    OF    THE    CEREBRAL    SINUSES    AND    VEINS      407 

and  severity  of  the  symptoms  depend  upon  the  virulence  of  the 
infecting  organism.  Usually  to  the  symptoms  of  the  peexisting 
condition  there  are  added,  more  or  less  suddenly,  evidence  of 
occlusion  of  a  cerebral  sinus  or  vein.  Some  cases  run  a  course 
to  a  fatal  termination  withm  a  few  days,  whereas  others  may 
last  for  weeks  or  months. 

Prognosis. — The  prognosis  of  a  primary  cerebral  thrombosis 
depends  upon  the  nature  of  the  initial  illness.  If  the  causative 
disease  can  be  controlled,  there  is  a  tendency  for  reabsorption 
of  the  clot  to  take  place,  and  the  only  permanent  s>Tnptoms 
will  be  those  that  arise  from  destruction  of  the  cerebral  tissue. 
The  prognosis  of  septic  or  secondary  thrombosis  is  extremely 
serious:  in  only  a  few  cases,  limited  to  affections  of  the  lateral 
sinus,  is  recovery  to  be  expected.  The  appearance  of  an  en- 
cephalitis, a  general  septicemia,  or  a  meningitis  makes  the  out- 
look almost  hopeless. 

Diagnosis. — The  diagnosis  of  a  primary  cerebral  venous  or 
sinus  thrombosis  is  made  when,  in  the  course  of  some  preexisting 
chronic  debilitating  disease,  there  occurs  evidence  pointing  to 
disturbance  of  the  functions  of  the  brain,  to  which  is  added  a 
localized  edema  of  the  face  or  scalp.  In  the  absence  of  edema 
the  diagnosis  is  made  only  with  difficulty.  If,  however,  in  the 
course  of  a  chronic  debilitating  disease  symptoms  pointing 
toward  cerebral  irritation  occur,  such  as  con\'ulsions  or  a  loss 
of  cerebral  functions,  e.  g.,  bilateral  weakness  or  paralysis,  a 
thrombosis  of  the  superior  longitudinal  sinus  should  be  suspected. 
The  diagnosis  of  a  secondary  or  septic  thrombosis  of  the  cerebral 
vein  or  sinuses  is  made  from  the  presence  of  a  primarv'  infectious 
condition,  to  which  are  added  the  symptoms  of  a  general  sys- 
temic infection  and  evidence  pointing  to  interference  T\dth  the 
circulation  of  blood  through  one  of  the  cerebral  sinuses,  together 
with  s}Tiiptoms  indicating  interference  with  the  functions  of  a 
localized  portion  of  the  brain. 

Treatment. — ^The  most  important  indication  is  the  prompt 
and  efficient  treatment  of  all  conditions  and  diseases  that  are 
likely  to  be  complicated  by  a  cerebral  sinus  thrombosis.  If 
sinus  thrombosis  has  occurred,  the  underlying  disease  should 
receive  prompt  and  skilful  treatment.    The  local  focus  of  in- 


4o8  MANUAL   OF  NERVOUS   DISEASES 

fection  demands  immediate  surgical  attention.  Pain  and  dis- 
comfort may  be  relieved  by  the  local  application  of  cold  or 
heat  to  the  head.  The  gastro-intestinal  symptoms  should 
receive  attention,  and  free  purgation  induced.  If  the  patient 
is  restless,  bromids  or  morphin  may  be  given;  for  the  temper- 
ature, cold  sponges  or  packs  may  be  applied.  General  supportive 
measures  are  indicated,  and  the  room  in  which  the  patient  lies 
should  be  quiet  and  well  ventilated. 

As  a  rule,  in  infective  thrombosis  there  is  only  one  mode  of 
treatment,  and  that  is  surgical.  The  infected  sinus  should  be 
exposed,  and  the  clot  removed.  The  operation  must,  of  course, 
be  undertaken  only  by  one  having  the  proper  experience,  and 
every  precaution  taken  to  prevent  the  spread  of  the  infected 
material.  This  is  best  accomplished  by  ligating  the  internal 
jugular  vein  before  operating  upon  the  lateral  sinus. 

ACUTE  NON-SUPPURATIVE   HEMORRHAGIC 
ENCEPHALITIS 

Etiology. — An  acute  non-suppurative  inflammation  of  the 
brain  may  occur  as  the  result  of  an  acute  infectious  disease. 
Cases  of  this  kind  have  been  known  to  occur  during  an  influenza 
epidemic;  they  may  also  occur  during  the  course  of  various 
infectious  diseases,  such  as  scarlet  fever,  measles,  whooping- 
cough,  mumps,  and  pneumonia,  and  may  complicate  erysipelas, 
ulcerative  endocarditis,  septicemia,  ptomain-poisoning,  chronic 
alcoholism,  trauma,  otitis  media,  chronic  auto-intoxication, 
etc. 

Pathology. — The  inflammatory  process  is  frequently  limited 
in  extent.  It  usually  occurs  in  circumscribed  areas,  and  may 
involve  the  cortex  and  the  central  ganglia.  It  may  be  limited 
to  the  gray  matter  of  the  aqueduct  of  Sylvius,  in  the  pons  or 
medulla,  and  is  sometimes  limited  to  the  distribution  of  one 
artery  or  to  symmetrically  situated  regions  of  the  brain.  The 
cerebral  tissue  in  the  aft'ected  area  presents  a  hyperemic  ap- 
pearance, with  numerous  small  punctate  hemorrhages,  and  is 
somewhat  swollen  and  more  moist  than  normal. 

Microscopically,  the  small  arteries  and  capillaries  are  seen  to 


NON-SUPPURATIVE   HEMORRHAGIC    ENCEPHALITIS      409 

be  dilated.  Rupture  of  the  vessel  walls  occurs,  and  there  is  an 
infiltration  of  white  and  red  cells.  The  cells  of  the  cerebral 
substance  show  evidence  of  irritation  and  disintegration. 

The  distribution  and  the  permanence  of  the  symptoms 
depend  upon  the  extent  and  severity  of  the  pathologic  changes 
that  take  place  in  the  cells  of  the  nervous  system.  Following 
the  destruction  of  the  nerve-cells,  secondary  degeneration 
occurs.  As  the  result  of  the  pathologic  process  small  or  large 
areas  of  sclerotic  tissue  or  cysts  are  formed.  The  size  of  these 
areas  may  vary  from  patches  so  small  as  to  be  hardly  discernible 
to  the  naked  eye,  to  destructive  processes  in  which  an  entire 
lobe  or  hemisphere  is  involved.  In  those  cases  in  which  the 
pathogenic  changes  occur  on  the  surface  of  the  brain  there  is 
frequently  an  involvement  of  the  meninges,  which  later  on 
causes  adhesion  of  the  membranes  to  the  cortex. 

Bacteriology. — In  most  cases  the  organism  causing  the  dis- 
ease may  be  found  in  the  foci  of  inflammation  in  the  brain. 

Symptoms. — The  disease  usually  develops  acutely.  Children 
are  affected  more  frequently  than  adults.  For  a  day  or  two 
the  patient  may  complain  of  headache,  irritability,  and  a  general 
feeling  of  illness.  Either  with  or  without  these  symptoms 
there  may  occur  a  sudden  chill,  followed  by  a  rise  of  temperature 
to  100°  to  104°  F.  The  temperature  remains  persistently  high, 
and  the  pulse  may  be  rapid  but  regular.  The  respiration  may 
be  regular  or  of  the  Cheyne-Stokes  type.  A  leukocytosis  is 
generally  present.  Later,  mental  confusion  and  delirium 
develop.  There  may  be  stiffness  of  the  neck,  convulsions,  or 
unconsciousness.  The  coma  is  rarely  so  deep  that  the  pupillary 
reflexes,  tendon  reflexes,  and  the  superficial  reflexes  are  lost. 

In  some  cases  the  delirium  is  marked,  and  may  occur  only 
as  the  stupor  disappears.  The  patient  may  die  during  the 
first  day  or  two,  the  coma  gradually  becoming  deeper  with  the 
increasing  temperature.  In  other  cases  the  disease  may  run  a 
more  protracted  course,  the  patient  remaining  more  or  less 
constantly  unconscious,  or  the  stupor  may  alternate  with 
delirium,  the  temperature  remaining  high,  and  the  pulse  being 
rapid  and  irregular.  Respiratory  disturbances  occur,  and  death 
intervenes  within  two  or  three  weeks.     In  other  cases  there  is  a 


41 0  MANUAL   or   NERVOUS   DISEASES 

gradual  subsidence  of  the  symptoms,  the  unconsciousness 
becoming  less  deep,  the  temperature  decreasing,  and  the  general 
constitutional  symptoms  disappearing.  It  is  in  these  cases 
that,  within  a  few  days  after  the  onset  of  the  illness,  symptoms 
appear  pointing  to  interference  with  some  portion  of  the  cerebral 
substance. 

If  the  brunt  of  the  disease  has  fallen  on  the  frontal  lobe 
or  its  conduction  pathways,  a  state  of  imbecility  develops,  and 
the  individual,  who  before  his  illness  was  bright,  may  after 
recovery  be  mentally  deficient. 

If  the  precentral  convolutions  are  involved,  weakness  or 
paralsyis  occurs.  If  the  occipital  lobes  are  affected,  visual 
disturbances  occur;  if  the  temporal  lobes  are  involved,  disturb- 
ances of  hearing  may  occur;  if  the  cerebellum  is  involved, 
there  may  be  disturbances  of  equilibrium,  ataxia,  nystagmus, 
etc.  In  those  cases  in  which  the  inflammatory  involvement  is 
limited  to  the  crura  and  the  adjacent  structures,  the  local 
symptoms  are  confined  to  the  eye  muscles,  and  there  occur 
ptosis,  strabismus,  opthalmoplegia,  nystagmus,  etc.  In  addition 
to  these  symptoms  there  may  be  ataxia,  optic  neuritis,  tremor, 
disturbances  of  speech,  staggering  gait,  etc.  This  type  of  case 
is  described  by  Wernicke  as  polioencephalitis  superior.  In 
some  cases  the  inflammatory  condition  may  be  limited  to  the 
lower  pons  and  medulla;  when  this  is  the  case  the  symptoms 
are  those  of  a  bulbar  palsy  of  acute  onset,  and  there  occur 
disturbance  of  speech,  swallowing,  and  respiration,  frequently 
accompanied  by  spastic  paralysis  or  weakness  of  all  four  ex- 
tremities, or  by  disturbance  of  sensation  in  the  parts  below  the 
lesion.  This  type  of  case  is  described  under  the  title  of  polio- 
encephalitis inferior. 

Any  combination  of  symptoms  may  occur,  dependent  upon 
the  severity,  the  distribution,  and  the  extent  of  the  inflam- 
matory condition. 

Course  and  Prognosis. — Some  cases  begin  with  high  tem- 
perature, marked  constitutional  symptoms,  coma  or  delirium, 
paralysis  or  convulsions,  etc.  They  may  terminate  fatally 
within  one  or  two  days.  Other  cases  may  likewise  begin  with 
marked  constitutional  disturbances,  accompanied  by  delirium 


NON-SUPPURATIVE   HEMORRHAGIC    ENCEPHALITIS      4 II 

or  coma,  convulsions  or  paralysis,  which  symptoms  may  con- 
tinue for  several  weeks,  a  fatal  termination  occurring  as  the 
result  of  inanition  or  cardiac  or  respiratory  disturbances. 

Those  cases  presenting  symptoms  of  a  polioencephalitis 
inferior  usually  terminate  fatally  within  a  short  time  as  the 
result  of  cardiac  or  respiratory  disturbances.  Cases  that  do 
not  manifest  such  marked  elevation  of  temperature  at  the  onset, 
and  in  which  the  coma  is  not  so  deep,  and  in  those  cases  in  which 
couMalsions  are  absent,  usually  after  a  short  time  the  temper- 
ature subsides  and  the  coma  disappears.  As  time  passes  a 
gradual  improvement  sets  in,  until  finally  the  prominent  symp- 
toms become  ver}^  limited  in  extent.  Unfortunately,  epilepsy 
is  a  somewhat  common  sequel  of  this  affection. 

Diagnosis. — The  diagnosis  is  made  from  the  acute  febrile 
onset,  and  from  the  constitutional  sjmiptoms,  which  are  rapidly 
followed  by  manifestations  pointing  to  local  cerebral  disease. 
The  diagnosis  of  acute  non-suppurative  hemorrhagic  enceph- 
alitis should  be  made  only  with  great  caution.  This  disease 
must  be  differentiated  from  the  cerebral  symptoms  that  occur 
especially  in  children  at  the  onset  of  the  various  infectious 
diseases,  such  as  influenza,  t}^hoid  fever,  pneumonia,  measles, 
etc.,  which  may  be  toxic  in  origin,  and  from  sinus  thrombosis 
and  acute  serous  meningitis. 

Acute  non-suppurative  hemorrhagic  encephalitis  is  distin- 
guished from  the  early  cerebral  toxic  states  accompanying  the 
infectious  diseases  by  the  fact  that  the  focal  cerebral  symptoms 
usually  develop  early,  are  well  marked,  and  remain  well  defined, 
whereas  in  the  toxic  or  irritative  conditions  the  focal  symptoms 
are  more  diffuse,  not  so  well  marked,  and  variable.  From 
sinus  thrombosis  this  condition  is  differentiated  by  the  absence 
of  local  edema  and  the  subacute  onset  of  s>Tnptoms,  pointing  to 
a  localized  cerebral  edema  and  destruction,  the  examination 
revealing  the  possible  source  of  a  sinus  involvement.  From 
an  acute  serous  meningitis  dift'erentiation  is  made  by  the  fact 
that  the  temperature  is  less  marked  as  compared  with  the  s>Tnp- 
toms,  the  irritative  manifestations,  such  as  cer\dcal  rigidity, 
hyperesthesia,  delirium,  and  comTilsions,  being  more  pronounced 
in  serous  meningitis.     In  encephalitis  the  temperature  is  higher 


412  MANUAL   or   NERVOUS   DISEASES 

and  the  symptoms  are  more  marked,  and  are  not  so  diffuse,  but 
more  constant.  The  former  disease  is  more  likely  to  occur  in 
older  individuals  and  in  those  in  whom  there  is  a  history  of 
alcoholism,  or  who  are  suffering  from  chronic  nephritis,  etc. 
The  latter  disease  is  more  prone  to  occur  in  children  and  in 
those  who  are  suffering  with  some  acute  febrile  illness. 

Treatment. — During  the  acute  stage  ice-caps  should  be  applied 
to  the  head,  and  cold  sponges  or  packs  be  ordered  to  reduce  the 
temperature.  Free  purgation  by  the  adminstration  of  calomel, 
followed  by  a  saline  or  by  castor  oil,  is  indicated. 

In  well-nourished  individuals  bleeding  may  be  advisable. 
The  patient  should  be  kept  in  a  quiet,  well-ventilated  room, 
and  if  he  is  very  restless,  sedatives  may  be  given.  After  the 
acute  stage  has  passed  the  treatment  of  the  subsequent  symp- 
toms is  the  same  as  that  indicated  for  the  relief  of  symptoms 
the  result  of  cerebral  circulatory  disturbances. 


INFANTILE  CEREBRAL  PARALYSIS 

This  condition  manifests  itself  during  the  first  few  years  of 
life,  the  symptoms  being  due  to  a  more  or  less  extensive  de- 
struction of  the  brain  substance. 

Etiology. — ^The  brain  may  be  affected  during  fetal  life,  but  is 
more  frequently  involved  during  labor  or  within  the  first  few 
years  of  life.  Heredity  plays  but  little  part  in  this  condition, 
although  there  may  be  a  tendency  to  the  transmission  of  a 
defective  cerebral  development.  During  fetal  life  there  may  be 
an  actual  deficiency  in  the  development  of  the  brain,  or  the 
brain  may  be  injured  as  the  result  of  trauma  to  the  gravid 
uterus.  Inflammatory  affections  may  involve  the  fetal  brain, 
and  states  of  malnutrition,  shock,  injury,  marked  emotional 
disturbances,  infectious  diseases,  chronic  intoxications,  etc., 
affecting  the  mother  may  interfere  with  the  normal  develop- 
ment of  the  fetal  brain.  During  labor  the  infantile  brain  may 
be  compressed  by  forceps,  or  prolonged  labor  may  bring  about 
circulatory  disturbances  and  compression.  Interference  with 
the  circulation  by  compression  of  the  umbilical  cord,  rupture 


INFANTILE    CEREBRAL   PARALYSIS 


413 


of  the  cerebral  vessels,  etc.,  may  bring  about  pathologic  states 
of  the  infantile  brain. 

After  birth  and  within  the  first  few  years  of  life  the  develop- 
ment of  the  infantile  brain  may  be  interfered  with  as  the  result 
of  injury,  inflammatory  states  secondary  to  infectious  diseases, 
toxic  conditions,  malnutrition,  circulatory  disturbances,  syphilis, 
diseased  states  of  the  ductless  glands,  convulsions,  etc. 

Pathology. — The  pathologic  changes  vary  much  in  distri- 
bution and  in  character,  and  are  largely  dependent  upon  the 
cause  of  the  cerebral  disease. 


Fig.  142  — Brain  from  a  case  of  infantile  cerebral  paralysis. 


The  causes  that  act  during  intra-uterine  life  most  frequently 
bring  about  large  cerebral  defects,  which  result  in  lack  of 
development  of  a  portion  of  the  brain.  The  undeveloped  area 
may  be  occupied  by  a  cyst,  giving  rise  to  a  true  porencephal- 
itis. There  may  be  a  defective  development  of  a  portion  of  the 
brain,  with  a  decrease  in  size  of  the  convolutions  and  a  lack  of 
development  of  the  cellular  elements;  in  other  cases  there  may 
be  deficient  development  of  the  entire  brain  and  of  the  cellular 
elements  (Fig.  142). 


414  MANUAL   or   NERVOUS   DISEASES 

As  the  result  of  injury,  disease,  or  nutritional  disturbances 
of  the  mother  there  may  occur  injury  or  disease  of  the  fetal 
brain,  which  may  give  rise  to  localized  or  diffuse  destructive 
conditions,  followed  by  lack  of  development,  cystic  formations, 
or  sclerotic  areas.  The  infantile  brain  may  be  injured  during 
labor,  meningeal  or  subpial  hemorrhages  occurring,  with  sub- 
sequent compression  or  softening,  followed  by  lack  of  develop- 
ment with  the  formation  of  scar  tissue  or  the  development  of 
cysts.  After  birth,  as  the  result  of  hemorrhage,  occlusion  of 
the  cerebral  vessels,  inflammatory  conditions,  and  the  like, 
there  occurs  a  deficiency  in  the  development  of  the  brain.  This 
may  be  more  or  less  extensive,  depending  upon  the  cause, 
and  be  accompanied  by  the  formation  of  scar  tissue,  cysts, 
or  the  development  of  a  hydrocephalic  condition. 

Symptoms. — If  the  causative  condition  occurred  prenatal  or 
during  labor,  symptoms  pointing  to  defective  functioning  of 
the  brain  manifest  themselves  either  shortly  after  birth  or 
within  the  first  few  months  of  life.  If  the  causative  condition 
occurs  postnatally,  the  symptoms  pointing  to  cerebral  involve- 
ment occur  along  with  the  evidence  of  a  more  or  less  acute 
cerebral  involvement. 

Owing  to  the  fact  that  the  pathologic  lesion  may  be  limited 
in  extent  there  occur  three  types  of  cases:  one  group  of  cases  is 
characterized  by  the  prominence  of  motor  symptoms;  another 
group  by  the  preeminence  of  mental  defects;  and  a  third  group 
by  the  prominence  of  sensory  defects.  Cases  also  occur  in 
which  symptoms  are  present  pointing  to  a  more  diffuse  cerebral 
involvement,  marked  by  the  presence  of  motor,  sensory,  and 
mental  manifestations,  or  any  combination  of  the  three.  Epi- 
lepsy may  occur  with  any  of  these  groups. 

In  those  cases  developing  during  intra-uterine  life  there  is 
noticed,  shortly  after  birth,  difficulty  in  nursing,  and  as  time 
goes  on  the  child  presents  either  evidence  of  a  lack  of  mental 
development  or  manifestations  of  sensory  defects,  such  as  blind- 
ness or  deafness.  In  addition,  there  may  be  observed  a  stiffness 
and  limitation  of  movement  of  one  or  both  sides  of  the  body, 
affecting  the  upper  and  lower  extremities  of  one  or  of  both 
sides.    Those  cases  that  develop  during  labor  usually  present 


INFANTILE  CEREBRAL  PARALYSIS         415 

evidences,  shortly  after  birth,  of  some  acute  cerebral  circulatory 
disturbance.  The  infant  may  breathe  with  great  difficulty,  is 
cyanotic,  does  not  cry,  may  display  convulsive  movements, 
which  may  be  limited  or  general,  and  cannot  be  made  to  take 
the  breast.  It  is  drowsy,  stupid,  or  unconscious,  and  may  re- 
main in  this  state  for  several  days  or  longer,  later  on  becoming 
very  irritable  and  restless  and  crying  more  or  less  constantly. 
Subsequently  symptoms  wdll  arise  pointing  to  localized  cerebral 
involvement. 

Those  cases  developing  during  the  first  few  years  of  life  more 
frequently  have  an  acute  onset,  with  a  temperature  ranging 
from  100°  to  104°  F.,  delirium  or  coma,  headache,  vomiting, 
and  sometimes  convulsions.  Symptoms  may  occur  pointing 
to  meningeal  irritation.  As  the  acute  illness  subsides  evidences 
of  more  or  less  serious  disturbance  of  the  cerebral  functions 
will  be  noticed.  Finallv,  these  cases  resemble  those  that  occur 
during  labor  or  prior  to  birth. 

The  type  in  which  the  motor  symptoms  are  the  most 
prominent  will  manifest  a  paralysis  or  weakness  that  may 
be  more  or  less  extensive  in  its  distribution.  Some  cases  are 
hemiplegic,  whereas  others  are  diplegic.  This  occurs  usually 
in  the  prenatal  cases  and  in  the  newborn.  The  upper  ex- 
tremity is,  as  a  rule,  more  seriously  affected,  than  the  lower 
extremity,  and  as  the  child  grows  older  it  often  learns  to  use  the 
affected  lower  extremity  or  extremities.  The  face  is  generally 
involved,  although  the  automatic  movements  are  not  affected. 
Many  of  these  patients  show  speech  disturbances  and  mental 
defects,  and  some  are  subject  to  convulsions  (Fig.  143). 

The  paralysis  is  always  of  a  spastic  type.  The  tendon  reflexes 
are  increased,  particularly  those  of  the  affected  extremities. 
Usually  there  is  noticed  a  tendency  to  muscle  contracture  in  the 
affected  part;  this  may  be  persistent  and  keep  the  limbs  flexed 
in  a  certain  position — the  upper  arm  may  be  held  close  to  the 
trunk;  the  elbow  may  be  flexed;  the  wrist  may  be  flexed  or  ex- 
tended; and  the  fingers  may  be  flexed  at  all  their  joints  and 
held  clenched,  or  may  be  extended  at  the  interphalangeal 
joints.  The  leg  is  usually  slightly  flexed  at  the  knee-joint, 
and  the  foot  is  extended,  with  either  eversion  or  inversion. 


4i6 


MANUAL   OF   NERVOUS   DISEASES 


In  other  cases,  instead  of  the  contracture  being  persistent, 
voluntary  movements  may  lead  to  overaction  and  tonic  spasms, 
constant  muscle  tension  being  present  and  increasing  with 
voluntary  movement.  In  some  cases  muscle  stiffness  with 
overaction  upon  voluntary  movements  is  the  only  evidence  of 
the  cerebral  involvement.     In  a  few  cases  associated  movements 


Fig.  143. — Infantile  cerebral  paralysis. 


occur :  thus  the  voluntary  movements  of  the  unaffected  extremity 
are  accompanied  by  more  or  less  similar  involuntary  move- 
ments on  the  affected  side. 

The  weakened  or  paralyzed  extremities  are  also  subject  to 
peculiar,  worm-like  contractions  which  affect  the  fingers  and 
hand  more  frequently  than  other  affected  portions;  these  are 
called  athetoid  movements.    In  some  cases  peculiar  purposeless 


INFANTILE    CEREBRAL   PARALYSIS  417 

involuntary  contractions  of  a  choreiform  nature  occur,  involving 
the  affected  extremities. 

The  abnormal  movements  sometimes  involve  the  face,  but 
the  upper  extremities  are  always  more  markedly  affected. 
These  abnormal  movements  are  usually  intensified  upon  volun- 
tary attempts  to  use  the  affected  portion  of  the  body. 

In  one  form  of  infantile  paralysis  known  as  Little^s  disease 
spastic  paralysis  or  weakness  affects  principally  the  lower  ex- 
tremities and  to  a  much  less  extent  the  upper  extremities. 
There  is  usually  little  or  no  mental  enf  eeblement,  and  no  tendency 
to  athetoid  movements  or  epileptic  attacks  exists.  This  con- 
dition usually  occurs  in  a  child  born  after  difficult  labor,  or  in 
one  who  is  born  prematurely  and  is  abnormally  small.  As 
the  child  develops  a  spastic  condition  involving  principally 
the  lower  extremities  is  observ^ed,  and  when  efforts  are  made  to 
walk  there  is  noticed  a  strong  adduction  of  both  legs.  As  the 
steps  are  taken  the  legs  become  crossed,  giving  rise  to  a  condition 
known  as  "scissors  gait." 

As  the  individual  grows  older  it  is  seen  that  the  affected 
limbs  do  not  develop  to  the  same  extent  as  the  unaffected 
limbs  do.  This  lack  of  development  affects  the  part  in  toto. 
There  are  no  qualitative  changes  in  the  electric  reaction,  and 
sensory  disturbances  are  rarely  present. 

Still  another  group  of  cases  are  seen  in  which  mental  enfeeble- 
ment  is  the  most  prominent  symptom.  In  these  there  is  noticed, 
either  after  an  acute  illness  or  dating  from  birth,  a  lack  or  absence 
of  mental  development.  All  grades  of  mental  deficiency,  from 
slight  peculiarities  of  character  and  mild  w^eakness  of  the  intellect 
to  idiocy,  are  obsen,'ed.  In  the  third  group  of  cases  the  promi- 
nent symptom  is  blindness  or  deafness.  In  some  cases  the  ex- 
istence of  homonymous  hemianopsia  is  discovered  on  examina- 
tion. In  those  cases  in  which  deafness  has  occurred  before 
the  individual  has  learned  to  talk  speech  is  never  acquired 
and  thus  deaf -mutism  exists. 

Many  of  the  cases  that  show  motor  symptoms  also  present 

evidence  of  some  mental  deficiency,  which  may  range  from  the 

very  mildest  grades  to  absolute  idiocy  (Fig.  144).     Convulsive 

seizures  are   of  frequent  occurrence  in  those  cases  in  which 

27 


4l8  MANUAL   OF   NERVOUS   DISEASES 

mental  or  sensorial  defects  are  the  prominent  symptoms.    Mental 

enfeeblement  frequently  occurs  along  with  the  sensorial  defects. 

Amaurotic  family    idiocy,    according    to    Sachs,    is    usually 

present  in  several  members  of  a  family.     The  children  in  such 


Fig.  144. — Infantile  cerebral  paralysis,  showing  motor  and  intellectual  defect 
(case  of  Dr.  G.  E.  Bennett).  ' 

a  family  present  at  birth  a  healthy  physical  and  mental  develop- 
ment, which  continues  for  several  months,  when  a  change  sets 
in,  and  they  become  weak  and  stupid.  Gradually  blindness 
develops,  due  to  optic  atrophy  (Fig.  145). 

Prognosis. — Complete  recovery  is  not  to  be  expected.    The 


INFANTILE    CEREBRAL    PARALYSIS 


419 


underlying  pathologic  condition  is  not  oi  a  progressive  nature, 
except  in  the  type  of  disease  known  as  amaurotic  family  idiocy. 
As  a  consequence,  there  is  no  progression  of  symptoms,  except 
in  amaurotic  cases.     The  sensory  defects  usually  do  not  improve. 


/ 


Fig.  145.— Am: 


uliocy, 


although  there  may  be  slight  improvement  in  the  intellectual 
and  the  motor  defects.  In  Little's  disease  considerable  improve- 
m.ent  may  take  place. 

The  convulsive  seizures  which  occur  may  be  held  in  check 


420  MANUAL   OF  NERVOUS  DISEASES 

and  their  severity  decreased  by  proper  medication,  but  their 
occurrence  cannot  be  absolutely  prevented.  These  individuals 
seem  particularly  susceptible  to  acute  illness,  and  the  greater 
number  of  cases  die  before  reaching  their  thirtieth  year. 

Diagnosis. — ^The  diagnosis  of  infantile  cerebral  palsy  usually 
presents  no  difficulty.  It  is  based  on  the  history  of  the  case, 
on  the  presence  of  weakness,  paralysis,  or  stiffness  of  a  hemi- 
plegic  or  a  diplegic  character,  in  conjunction  with  mental  en- 
feeblement,  more  or  less  marked,  and  at  times  sensory  defects, 
abnormal  movements,  and  epilepsy.  In  these  cases,  even 
when  there  is  a  decrease  in  the  size  of  the  affected  extremities, 
the  electric  reactions  are  qualitatively  normal  and  the  tendon 
reflexes  are  increased. 

The  diagnosis  of  Little's  disease  is  made  from  the  presence 
of  a  spastic  weakness  or  paralysis  of  all  four  extremities,  the 
lower  being  affected  to  a  much  greater  extent  than  the  upper; 
the  absence  of  mental  defects  and  of  epilepsy;  and  the  fact  that 
the  affection  manifests  itself  within  the  first  few  months  of 
life.  The  diagnosis  of  amaurotic  family  idiocy  is  made  from  the 
presence  of  a  progressive  spastic  weakness  or  paralysis,  hemi- 
plegic  or  diplegic  in  distribution,  accompanied  by  optic  atrophy, 
with  a  peculiar  fundal  change  (Fig.  146).  The  fact  that  the 
affection  occurs  usually  in  several  members  of  a  family  during 
the  first  few  months  of  life  is  also  of  diagnostic  value. 

Treatment. — ^The  treatment  of  this  condition  is  largely 
prophylactic  in  nature ;  the  pregnant  mother  should  be  properly 
nourished  and  cared  for  during  the  period  of  pregnancy,  should 
be  spared  all  unnecessary  emotional  disturbances,  and  guarded 
against  trauma,  etc.  During  labor  the  head  of  the  child  should 
be  properly  protected,  and  the  delivery  should  be  effected 
under  proper  medical  supervision,  so  as  to  prevent  undue 
pressure  of  the  head  or  a  too  prolonged  labor.  In  other  cases, 
after  prolonged  or  difficult  labor,  when  the  presence  of  a  sub- 
dural hemorrhage  is  suspected,  the  patient  should  be  carefully 
watched,  and  if  convulsions  or  stupor  occur,  surgical  inter- 
vention is  to  be  seriously  considered. 

The  treatment  of  the  acute  cerebral  conditions  occurring 
in  early  childhood,  such  as  meningitis,  encephalitis,  hemorrhage, 


INFANTILE    CEREBRAL   PARALYSIS  42 1 

thrombosis,  etc.,  is  the  same  as  that  which  has  been  described 
in  the  previous  chapters. 

Later  the  treatment  should  be  directed  toward  preventing 
the  development  of  contractures;  this  is  best  accomplished  by 
massage,  passive  movements,  and  the  faradic  current  applied 
to  the  weaker  muscles.  If,  in  spite  of  these  measures,  contrac- 
tures still  tend  to  occur,  they  should  be  overcome  by  the  applica- 
tion of  splints  or  of  different  forms  of  orthopedic  apparatus. 
In  cases  in  which  the  abnormalities  of  movement  seriously 


Fig.  146. — The  fundus  in  amaurotic  family  idiocy. 

interfere  with  the  comfort  of  the  patient,  the  intradural  section 
of  several  posterior  nerve-roots  by  Foerster's  method  may 
give  relief.  In  some  cases  the  mental  defects  can  be  improved 
by  education;  in  other  cases  nothing  can  be  accomplished.  The 
blindness  and  deafness  are  not  amenable  to  treatment,  although 
some  deaf  patients  may  be  helped  by  those  accustomed  to 
teaching  the  deaf  and  dumb. 

Epilepsy  can  be  controlled  to  a  certain  extent  by  the  use  of 
bromids  or  other  sedatives. 

The  patient  should  be  kept  clean,  and  protected  from  ex- 


422  MANUAL   OF   NERVOUS   DISEASES 

posure.  The  diet  should  be  li^rht  but  nutritious,  and  proper 
supervision  of  the  bowels  and  bladder  should  be  maintained. 
Every  effort  should  be  made  to  see  that  the  patient  is  cleanly 
in  his  habits.  If  there  is  reason  to  believe  that  an  increased 
intracranial  pressure  exists,  especially  if  choked  disc  is  present, 
cerebral  decompression  is  indicated.  In  many  cases  in  which 
this  was  performed  the  patient  has  been  benefited.  When  the 
examination  reveals  the  presence  of  a  local  cortical  irritative 
lesion,  operation  is  justifiable.  Each  case  should  be  carefully 
considered  as  to  the  advisability  of  performing  a  cranial  opera- 
tion, for  in  the  vast  majority  of  cases  this  procedure  is  absolutely 
useless.  In  most  cases  the  best  results  are  had  from  careful 
nursing,  proper  attempts  at  education,  relief  of  the  epilepsy, 
the  placing  of  the  patient  amid  agreeable,  cheerful,  protected 
surroundings,  relief  of  the  abnormal  movements,  and  the 
prevention,  so  far  as  possible,  of  unfavorable  positions  of  the 
limbs  by  means  of  massage,  electricity,  mechanical  appliances, 
or  operative  procedures. 

HYDROCEPHALUS 

Etiology. — This  condition  may  be  congenital  or  acquired. 
Chronic  intoxication,  syphilis,  acute  infectious  diseases  affecting 
the  mother  during  pregnancy,  trauma,  and  heredity  seem  to  be 
the  most  common  predisposing  conditions  in  the  development 
of  a  congenital  hydrocephalus.  In  the  acquired  form  the  con- 
dition may  have  been  slight  at  birth,  and  remained  latent  for 
some  time,  developing  later  as  the  result  of  injury,  exposure, 
etc.  An  acquired  hydrocephalus  may  be  secondary  to  tumors 
that  exert  pressure  upon  the  veins  of  Galen  or  upon  the  aqueduct 
of  Sylvius,  or  it  may  be  secondary  to  inflammatory  diseases  of 
the  meninges  that  close  the  foramen  of  Magendie,  and  thus 
prevent  the  flow  of  cerebrospinal  fluid  into  the  subdural  space. 
In  other  cases  there  is  an  increase  of  the  cerebrospinal  fluid 
in  wasting  diseases,  in  nephritis,  and  in  atrophy  of  the  con- 
volutions of  the  brain  in  old  age.  The  condition  may  also  be 
secondary  to  a  serous  meningitis  of  the  ventricles,  in  which  case 
it  may  run  an  acute  or  a  chronic  course.     This  variety  is  believed 


HYDROCEPHALUS  423 

to  be  due  to  injury,  exhaustion,  chronic  toxemia,  pneumonia, 
typhoid  fever,  tuberculosis,  and,  less  frequently,  other  infectious 
processes. 

Pathology. — This  condition  is  marked  by  the  presence  of 
an  excessive  quantity  of  fluid  either  in  the  cerebral  ventricles, 
giving  rise  to  an  mternal  hydrocephalus,  or  between  the  brain  and 
the  dura,  giving  rise  to  an  external  hydrocephalus.  The  fluid 
is  generally  clear  and  colorless,  and  contains  but  little  albumin 
and  a  small  amount  of  lime  salts.  In  some  cases  the  hydro- 
cephalus may  be  limited  to  a  single  ventricle;  as  a  rule,  the 
fourth  ventricle   is   least  affected.     The   development   of   the 


Fig.  147. — Hydrocephalus. 

brain  is  almost  always  retarded,  and  in  some  cases  the  walls 
of  the  hemisphere  may  be  merely  a  layer  several  millimeters  in 
thickness,  the  convolutions  and  sulci  being  completely  ob- 
literated (Fig.  147). 

In  the  congenital  cases,  and  in  those  developing  before  ossifica- 
tion of  the  sutures  of  the  cranial  bones  has  taken  place,  the  skull 
is  increased  in  size  and  the  cranial  bones  are  reduced  in  thick- 
ness. The  head  becomes  irregularly  globular  in  shape,  with 
prominent  frontal  and  parietal  protuberances.  The  choroid 
plexuses  are  frequently  enlarged.  In  some  cases  an  ependym- 
itis  of  the  ventricles  is  found,  with  thickening  of  the  ventricular 
lining,  closing  the  foramen  between  the  ventricles;  at  times 


424  MANUAL   OF   NERVOUS   DISEASES 

there  is  a  closure  of  the  foramen  of  Magendie.  Defective 
development  of  the  cerebellum  and  of  the  brain-stem  is  occasion- 
ally observed.  Those  cases  that  occur  after  ossification  of  the 
cranial  sutures  do  not  show  any  increase  in  the  size  of  the  head, 
and  the  amount  of  fluid  present  is  smaller.  In  these  cases  the 
pressure  is  exerted  more  directly  upon  the  brain  substance, 
with  subsequent  distruction  of  the  brain  tissue. 

Symptoms. — If  the  hydrocephalic  enlargement  of  the  head 
is  well  marked  before  birth,  labor  is  rendered  difficult,  and  is 
sometimes  impossible  without  a  mutilating  operation.  In 
those  cases  in  which  the  condition  is  not  pronounced  at  birth 
it  usually  appears  during  the  first  six  months  or  year.  When 
the  condition  develops  after  an  acute  or  a  chronic  illness,  before 
ossification  of  the  cranial  sutures  has  taken  place,  there  occurs 
a  more  or  less  rapid  enlargement  of  the  head.  The  internal 
pressure  is  manifested  by  the  bulging  of  the  fontanels,  which 
increase  in  size.  As  the  condition  progresses  there  is  a  marked 
disproportion  between  the  size  of  the  skull  and  the  face;  the 
frontal  and  parietal  protuberances  project  over  the  face  and 
ears;  the  orbits  are  frequently  directly  downward  instead  of 
forward,  and  the  veins  of  the  scalp  are  prominent. 

In  time  there  is  noticed  a  defective  development  of  the 
intellect.  Optic  atrophy,  nystagmus,  and  strabismus  are  very 
common.  These  children  are  usually  inactive,  and  may  be 
restless  and  irritable.  In  other  cases  there  is  a  marked  tendency 
to  the  development  of  stuporous  states.  Many  of  these  children 
cannot  learn  to  speak,  or  if  they  do,  speech  is  acquired  late 
and  is  often  defective.  Vomiting  is  frequently  present,  or  may 
be  induced  by  attempts  at  movement.  Such  children  learn  to 
walk  late,  if  at  all.  Frequently  spastic  weakness  or  paralysis 
is  present  on  one  or  both  sides,  more  often  in  the  legs,  and  con- 
vulsive seizures  are  not  uncommon. 

When  an  internal  hydrocephalic  condition  occurs  after 
closure  of  the  sutures  and  fontanels,  the  symptoms  are  those 
pointing  to  increased  intracranial  pressure,  e.  g.,  pain,  headache, 
vomiting,  vertigo,  insomnia,  restlessness,  stuporous  states  alter- 
nating with  delirium,  spastic  paralysis,  choked  disc,  strabismus, 
and    sometimes    nystagmus    and    pupillary    disturbances.    A 


HYDROCEPHALUS  425 

slight  exophthalmos  is  usually  present,  and  rarely  there  is  a 
spontaneous  escape  of  cerebrospinal  fluid  through  the  nose. 

Course  and  Prognosis. — ^The  duration  of  the  congenital  cases 
varies  considerably;  most  cases  run  a  rapidly  fatal  course,  the 
patient  dying  within  the  first  few  months  of  life.  Other  cases 
in  which  the  hydrocephalus  is  not  so  well  marked  last  a  longer 
time,  and  the  patients  are  capable  of  a  fair  amount  of  mental 
development.  Very  mild  grades  of  hydrocephalus  also  occur 
in  which  spontaneous  arrest  of  the  condition  may  take  place. 
These  individuals  are  capable  of  normal  mental  development 
and  may  attain  old  age.  From  my  experience  it  would  appear 
that  those  cases  which  are  most  marked  and  which  develop 
soon  after  birth  lead  to  a  rapidly  fatal  termination.  The 
course  and  prognosis  of  an  acquired  hydrocephalus  are  depend- 
ent principally  upon  the  cause;  as  a  rule,  the  outlook  is  rather 
grave,  although  in  some  cases  spontaneous  arrest  of  the  condition 
takes  place. 

Diagnosis. — ^Those  cases  accompanied  by  hydrocephalic 
enlargement  usually  present  no  difficulty  in  diagnosis.  The 
condition  may  be  differentiated  from  rickets  by  the  globular 
shape  of  the  head  in  hydrocephalus  in  contradistinction  to  the 
rectangular  shape  of  the  head  in  rickets;  the  absence  of  other 
signs  of  rickets  in  hydrocephalus,  and  their  appearance  in  the 
long  bones  and  costal  extremities  in  rickets.  In  later  life 
hydrocephalus  must  be  differentiated  from  hyperostosis  cranii; 
in  the  latter  condition  the  increase  in  the  size  of  the  head  is  due 
to  thickening  of  the  cranial  bones,  which  can  be  detected  by 
x-ray  examination.  In  this  disease  the  bones  of  the  face  and 
spine  are  also  usually  thickened.  From  acromegaly  hydro- 
cephalus is  differentiated  by  the  fact  that  in  the  former  condition 
there  is  an  associated  enlargement  of  the  hands  and  feet,  a 
marked  enlargement  of  the  lower  jaw,  and  a  thickening  of  the 
frontal  bones.  The  diagnosis  of  a  hydrocephalic  condition 
after  ossification  of  the  cranial  bones  has  taken  place  is  a  matter 
of  great  difficulty  in  those  cases  in  which  no  enlargement  has 
taken  place.  In  these  cases  the  diagnosis  of  the  causative 
condition  is  usually  made,  and  the  presence  of  the  hydrocephalus 
is  inferred. 


426  MANUAL   OF   NERVOUS   DISEASES 

Treatment. — In  those  cases  in  which  syphiHs  is  suspected  as 
being  a  factor  in  the  causation  of  the  condition  mercurial  in- 
unctions and  potassium  iodid  internally  may  be  of  value. 
Cold  applications  should  be  made  to  the  head  and  the  bowels 
be  kept  well  open.  The  amount  of  liquids  ingested  should  be 
limited.  In  those  cases  in  which  there  is  restlessness,  pain, 
or  convulsions,  relief  may  be  had  by  the  administration  of 
sedatives.  Treatment  of  the  underlying  condition  is  of  the 
utmost  importance.  If  the  hydrocephalus  is  the  result  of  a 
meningitis,  with  closure  of  the  foramen  of  Magendie,  benefit 
may  result  from  a  suboccipital  operation  and  the  breaking  up 
of  meningeal  adhesions.  In  those  cases  due  to  pressure  by  a 
tumor  operation  for  removal  of  the  growth  must  be  considered. 
The  surgical  treatment,  consisting  of  repeated  ventricular 
puncture  and  ventricular  drainage,  strapping  of  the  skull,  etc., 
has  been  very  unsatisfactory. 

ABSCESS   OF  THE  BRAIN 

The  formation  of  a  brain  abscess  is  always  secondary  to  a 
purulent  encephalitis  produced  by  microorganisms.  Trauma 
to  the  head  is  one  of  the  common  causes  of  cerebral  abscesses — 
usually  the  injury  produces  a  fracture,  wdth  subsequent  sup- 
puration of  the  wound  and  secondary  involvement  of  the  brain. 
Infected  wounds  of  the  scalp  may  also  be  a  cause  of  cerebral 
abscess.  An  abscess  may  form  on  the  brain  shortly  after  an 
injury,  or  an  interval  of  some  time  may  elapse  before  the  cerebral 
symptoms  manifest  themselves,  the  health  remaining  compara- 
tively good  in  the  meantime. 

Another  very  common  cause  of  brain  abscess  is  chronic 
suppurative  middle-ear  disease.  In  these  cases  there  is  usually 
a  history  of  repeated  attacks  of  otitis  media,  or  of  the  presence, 
at  some  previous  time,  of  a  purulent  discharge  from  the  ear. 
In  these  cases  erosion  and  infection  of  the  bones  of  the  tympanic 
cavity  or  of  the  mastoid  cells  occur:  in  the  former  case  the  tem- 
poral lobes  are  infected,  and  in  the  latter  case  the  infection 
invades  the  cerebellum.  The  abscess  may  communicate  by 
means  of  a  fistula,  through  the  thickened  and  inflamed  dura, 


ABSCESS    OF    THE    BRAIN 


427 


Fig.  148. — Abscess  of  the  cerebellum  (case  of  Dr.  Charles  Bagley). 


with  the  bone  lesion,  but  in  most  cases  there  is  a  layer  of  brain 
tissue  between  the  abscess  and  the  bone  lesion,  the  infecting 


428  MANUAL  OF  NERVOUS  DISEASES 

organism  invading  the  brain  by  means  of  the  perivascular 
lymphatic  space.  Rarely  brain  abscesses  are  secondary  to 
suppurative  processes  affecting  other  cranial  bones,  pyogenic 
infection  of  the  nasal  cavity  or  orbit,  erysipelas,  etc.  In  some 
few  cases  brain  abscesses  occur  in  general  pyemic  conditions 
secondary  to  ulcerative  endocarditis,  puerperal  infection, 
suppuration  in  the  bones  or  joints,  gangrene  in  the  lungs,  etc. 
In  this  latter  group  of  cases  multiple  abscesses,  as  a  rule,  develop. 
The  abscess  may  also  occur  in  connection  with  one  of  the  in- 
fectious diseases,  such  as  typhoid,  influenza,  epidemic  cerebro- 
spinal meningitis,  measles,  etc. 

Cerebral  abscesses  occur  more  frequently  in  males  than  in 
females,  and  are  most  common  between  the  tenth  and  the 
thirtieth  year. 

Pathology. — In  cases  due  to  trauma  the  abscess  is  usually 
situated  in  the  subjacent  brain  tissue.  When  secondary  to 
otitis  media,  the  abscess  is  located  on  the  same  side  of  the  brain 
as  the  ear  that  is  affected,  and  is  generally  either  in  the  temporal 
lobe  or  in  the  cerebellum  (Fig.  148).  In  rare  cases  a  localized 
encapsulated  abscess  involving  the  dura  and  the  cortex  may 
occur;  when  such  abscess  forms,  it  is  found  either  in  the  middle 
or  in  the  posterior  fossa  of  the  skull.  Streptococci,  staphylococci, 
pneumococci,  the  influenza  bacillus,  typhoid  and  tubercle  bacilli, 
etc.,  have  all  been  found  in  cerebral  abscesses. 

Cerebral  abscesses  may  be  small  or  large,  encapsulated  or 
irregular  in  outline,  and  single  or  multiple.  They  may  be  of 
rapid  or  of  slow  growth.  In  the  earlier  stage  there  is  a  localized 
purulent  encephalitis,  followed  by  a  gradual  breaking  down  of 
brain  tissue,  with  the  formation  of  pus  within  an  irregular 
cavity.  This  cavity  has  no  distinct  walls,  but  is  surrounded 
by  brain  tissue  that  is  more  or  less  affected,  and  that  contains 
hemorrhagic  areas.  In  other  cases  there  is  a  more  or  less  defi- 
nite wall  formation,  and  even  in  these  cases  there  may  be  an 
involvement  of  the  brain  tissue  beyond  this  wall,  with  sub- 
sequent extension  of  the  abscess.  The  majority  of  abscesses 
that  have  existed  for  any  considerable  length  of  time  are  sur- 
rounded by  a  definite  capsule.  This  capsular  w^all  begins  to 
form  as  early  as  the  second  week,  and  if  the  abscess  persists  for 


ABSCESS    OF    THE    BRAIN  429 

some  time  the  wall  may  become  thick,  resistant,  and  even 
calcify.  In  many  cases,  owing  to  the  fact  that  the  brain  tissue 
surrounding  the  abscess  is  also  infected,  there  is  a  breaking 
down  of  the  walls,  with  an  extension  of  the  abscess;  thus  the 
abscess  may  rupture  into  the  ventricles  or  on  to  the  surface  of 
the  brain. 

The  pus  of  a  brain  abscess  is  usually  green  or  yellow  in  color, 
often  has  an  extremely  disagreeable  odor,  and  sometimes 
contains  disintegrated  brain  tissue. 

Symptoms. — The  symptoms  of  the  early  stages  of  brain 
abscesses  are  usually  masked  by  those  of  the  causative  condition, 
and  hence  are  often  overlooked.  A  careful  consideration  of 
the  history  of  brain  abscesses  will  permit  one  to  distinguish 
three  stages,  which  sometimes  merge  rapidly,  and  at  other 
times  very  slowly,  into  each  other.  In  the  first  or  stage  of  in- 
vasion, there  occur  the  symptoms  of  the  underlying  disease, 
together  with  evidence  pointing  to  involvement  of  the  brain 
tissue,  such  as  localized  or  diffuse  headache,  restlessness,  stupor 
or  delirium,  irritability,  indifference,  rarely  choked  disc,  etc. 
In  this  stage  the  temperature  may  be  high,  subnormal,  or 
irregular;  chills  and  profuse  sweats  may  occur,  and  a  leuko- 
cytosis is  usually  present.  This  stage,  which  may  continue  for 
from  a  few  days  to  several  weeks,  may  be  followed  by  the  sec- 
ond or  third  stage. 

If  the  second  stage  follows,  there  is  a  remission  of  symptoms, 
and  the  patient  enters  the  latent  stage,  in  w^hich  the  headache 
is  less  severe  or  disappears,  the  temperature  remaining  sub- 
normal or  showing  an  occasional  rise.  In  this  stage  intense 
headaches  may  arise  without  apparent  cause,  and  there  may  be 
a  change  in  the  mental  characteristics  of  the  patient — he  may 
become  irritable  or  indifferent,  or  exhibit  a  gradually  increasing 
mental  dulness  and  slowness  of  thought. 

The  patient  may  remain  in  this  stage  for  a  period  varying 
from  a  very  short  time  to  many  years,  when,  more  or  less  sud- 
denly, the  symptoms  of  the  third  stage  may  be  ushered  in,  or 
the  second  stage  may  gradually  pass  into   the  third  stage. 

In  the  third  stage  the  headache  becomes  more  persistent 
and  severe,  and  vomiting  and  vertigo  may  occur.    The  tem- 


430  MANUAL   OF   NERVOUS   DISEASES 

perature  remains  subnormal;  the  pulse  becomes  slow,  the  beats 
ranging  from  50  to  70  a  minute.  Convulsive  attacks  may 
occur,  together  with  paralysis  of  the  cranial  nerves,  optic 
neuritis,  etc. 

In  some  cases  the  stage  of  invasion  passes  more  or  less  rapidly 
into  the  terminal  stage.  In  addition  to  the  symptoms  of  the 
causative  condition,  the  patient  becomes  stuporous  or  delirious, 
and  headache  and  vomiting  occur.  The  temperature  may  be 
very  high,  the  pulse  irregular,  and  leukocytosis,  chills,  con- 
vulsive seizures,  etc.,  may  supervene.  The  patient  becomes 
emaciated  and  there  is  great  prostration;  symptoms  of  meningeal 
involvement  may  set  in,  and  death  terminates  the  condition. 

There  is  another  group  of  cases  in  which,  after  the  stage  of 
invasion,  there  occurs  a  period  during  which  the  patients  are 
apparently  without  symptoms  for  a  considerable  length  of  time, 
varying  from  months  to  many  years.  These  patients  may 
gradually  develop  symptoms  suggestive  of  cerebral  tumor,  but 
which  are  accompanied  by  subnormal  or  unexplainable  rises  of 
temperature,  leukocytosis,  and  at  times  chills  or  general  septic 
manifestations.  Other  patients  in  the  latent  stage  may  sud- 
denly, without  premonitory  symptoms,  develop  an  acute 
attack  resembling  a  stroke  of  apoplexy;  this  may  be  ushered  in 
by  convulsive  seizures,  and  be  followed  by  rise  in  temperature, 
leukocytosis,  chills,  delirium  or  stupor,  nystagmus,  pupillary 
inequalities,  etc.,  death  occurring  within  a  short  time. 

Diagnosis. — In  formulating  a  diagnosis  of  cerebral  abscess 
the  history  of  a  focus  of  infection  or  the  appearance  of  one  of 
the  commoner  preexisting  causes  of  brain  abscess  is  of  the 
greatest  importance.  When  there  is  no  history  or  evidence  of  a 
probable  cause  for  the  condition  only  a  tentative  diagnosis 
can  be  made.  If,  shortly  after  an  injury  to  the  skull,  there  be 
added  to  the  local  manifestations  symptoms  pointing  to  a  local 
cerebral  disturbance  in  an  area  corresponding  closely  to  the 
traumatic  lesion, — symptoms  accompanied  by  fever,  chills, 
leukocytosis,  etc., — the  diagnosis  of  a  cerebral  abscess  or  of  a 
meningitis  may  be  made.  It  is  a  matter  of  great  difficulty 
in  these  cases  to  distinguish  between  these  two  conditions: 
In  meningitis  the  irritative  symptoms  are  more  marked;  the 


ABSCESS    OF    THE    BRAIN  43 1 

temperature  is  apt  to  be  higher;  the  pulse  is  rapid  and  irregular; 
there  is  a  tendency  for  the  disease  to  spread  rapidly;  cervical 
rigidity  and  cranial  nerve  palsies  occur.  In  cerebral  abscess 
the  symptoms  are  more  apt  to  remain  localized;  temperature 
is  less  likely  to  be  high;  the  pulse  becomes  slower,  and  stupor 
or  coma  develops;  and  if  there  is  much  increased  intracranial 
pressure,  choked  disc  occurs. 

In  those  cases  in  which  cerebral  symptoms  occur  some  time 
after  an  injury  to  the  head  differentiation  must  be  made  between 
cerebral  abscess,  brain  tumor,  and  traumatic  neurosis.  Trau- 
matic neurosis  is  characterized  by  the  absence  of  fever,  of  slow 
pulse,  and  of  focal  symptoms,  and  by  the  presence  of  sensory 
and  vasomotor  symptoms,  and  subjective  vertigo.  There  is 
also  marked  variation  of  symptoms,  and  usually  the  evidence  of 
a  neuropathic  disposition.  In  brain  tumor  the  development 
of  the  symptoms  is  more  apt  to  be  insidious;  choked  disc  is 
frequently  present  early;  fever  and  leukocytosis  are  generally 
absent,  and  the  focal  symptoms,  when  present,  show  a  gradual 
but  regular  tendency  toward  progression.  In  cerebral  abscesses 
manifesting  themselves  some  time  after  an  injury  the  onset  is, 
as  a  rule,  more  sudden,  and  is  accompanied  by  temperature, 
chills,  and  leukocytosis.  Remissions  occur  more  or  less  fre- 
quently, and  the  progress  of  the  condition  is  irregular. 

If  a  cerebral  abscess  is  secondary  to  a  chronic  otitis  media, 
it  must  be  differentiated  from  thrombosis  of  the  lateral  sinus 
and  meningitis.  From  thrombosis  of  the  lateral  sinus  it  is 
differentiated  by  the  presence,  in  thrombosis,  of  a  swelling, 
tenderness,  and  edema  of  the  mastoid  process;  tenderness  and 
swelling  and  sometimes  a  cord-like  appearance  of  the  jugular 
vein  on  the  side  of  the  neck.  The  temperature  is  generally 
irregular,  ranging  from  the  subnormal  to  104°  F.  or  over;  chills 
are  frequent,  and  the  pulse  is  rapid  and  irregular.  In  meningitis 
the  onset  is  usually  more  rapid;  the  irritative  symptoms,  such 
as  hyperesthesia,  cervical  rigidity,  convulsions,  and  delirium,  are 
generally  present;  the  temperature  varies,  but  rarely  goes  below 
normal ;  the  pulse  is  apt  to  be  rapid,  irregular,  and  intermittent ; 
paralysis  of  the  cranial  nerves  and  optic  neuritis  occur  early; 
leukocytosis  is  marked;  examination  of  the  spinal  fluid  reveals 


432  MANUAL   OF   NERVOUS   DISEASES 

the  presence  of  microorganisms  and  leukocytes.  In  abscess  the 
onset  is  usually  less  sudden,  the  irritative  symptoms  are  generally 
absent,  the  temperature  is  frequently  subnormal,  the  pulse  is 
slow,  and  choked  disc  occurs  later;  local  cerebral  symptoms 
which  are  very  slowly  progressive  are  prominent,  and  the  spinal 
fluid  does  not  show  the  presence  of  leukocytes  or  of  micro- 
organisms. Some  cases  of  otitis  media  are  accompanied  by 
marked  cerebral  symptoms,  without  the  development  of  brain 
involvement.  These  cases  usually  promptly  clear  up  when 
proper  treatment  is  directed  toward  the  ear  condition.  The 
leukocyte  count  rarely  goes  above  12,00c,  and  optic  neuritis 
and  symptoms  pointing  to  local  cerebral  involvement  do  not 
occur. 

The  diagnosis  of  a  cerebral  abscess  occurring  during  the  course 
of  the  acute  infectious  diseases,  septic  conditions,  in  purulent 
diseases  of  the  lungs,  etc.,  is  always  made  with  difficulty.  The 
presence  of  cerebral  symptoms,  which  may  be  of  acute  onset, 
the  occurrence  of  remissions,  together  with  localized  signs  and 
evidence  of  increased  intracranial  pressure,  should  always 
arouse  a  strong  suspicion  of  the  presence  of  a  cerebral  abscess. 

The  diagnosis  of  the  location  of  a  cerebral  abscess  is  always 
a  matter  of  great  importance,  and  should  be  made  from  the 
presence  of  the  localizing  symptoms.  Cerebral  abscesses  follow- 
ing injury  to  the  skull  usually  occur  in  the  portion  of  the  brain 
situated  adjacent  to  the  traumatic  lesion.  Abscesses  secondary 
to  middle-ear  disease  commonly  involve  the  temporosphenoidal 
lobe  or  the  cerebellum,  and  one  cannot  always  determine 
with  certainty  the  location  of  such  an  abscess.  When  one  ear 
only  is  affected,  the  abscess  is  always  on  the  side  of  the  affected 
ear.  Examination  of  the  ear  to  discover  the  site  of  the  carious 
process  is  of  great  importance,  as  those  abscesses  that  form 
subsequent  to  necrosis  of  the  roof  of  the  middle  ear  generally 
develop  in  the  temporal  lobe,  whereas  those  which  occur  second- 
ary to  a  necrosis  of  the  posterior  wall  or  of  the  mastoid  cells 
usually  involve  the  cerebellum. 

The  presence  of  cerebellar  ataxia,  stiffness  of  the  neck, 
nystagmus,  choked  disc,  or  symptoms  pointing  tow^ard  involve- 
ment of   the  pons  and  medulla   indicate   cerebellar   involve- 


CEREBRAL   TUMORS  433 

ment.  Symptoms  consisting  of  disturbance  of  hearing,  hemi- 
anopsia, and  sensory  disorders  point  toward  temporal  lobe 
involvement.  Suppurative  processes  secondary  to  septic  con- 
ditions are  usually  multiple,  and  may  give  rise  to  no  local- 
izing signs. 

Prognosis. — The  outlook  is  grave,  death  occurring  from  the 
development  of  a  cerebral  edema  or  from  the  bursting  of  the 
abscess  into  the  meninges  or  ventricles,  and  setting  up  a  purulent 
meningitis.  The  probability  of  recovery  of  an  individual  who 
has  a  cerebral  abscess  is  dependent  mainly  on  the  possibility 
of  successfully  evacuating  the  contents  of  such  an  abscess 
cavity,  and  upon  the  formation  or  the  presence  of  an  encapsulat- 
ing membrane  that  w411  preclude  extension  of  the  infection  to 
some  adjacent  cerebral  tissue.  A  certain  number  of  cases, 
even  if  properly  opened  and  treated,  will  succumb  as  the  result 
of  the  slow,  intermittent  extension  of  infection  to  the  adjacent 
cerebral  tissue  and  a  failure  of  the  abscess  cavity  to  be  completely 
obliterated. 

Treatment. — ^The  treatment  of  this  condition  is  purely  sur- 
gical. The  cranial  cavity  should  be  opened  over  the  suspected 
location  of  the  abscess,  the  strictest  aseptic  precautions  being 
observed.  If  time  permits,  it  is  advisable,  by  irritation  of  the 
meninges,  to  cause  a  closing  off  of  the  rest  of  the  cerebral  cav- 
ity by  the  formation  of  adhesions  between  the  membranes 
at  the  operative  site;  then,  in  about  twenty-four  or  thirty-six 
hours  after  this  has  occurred,  the  abscess  cavity  should  be  freely 
opened,  and  measures  instituted  to  allow  free  drainage.  This 
is  most  important,  as  unless  the  abscess  cavity  granulates  or 
fills  up  from  the  bottom,  a  recurrence  will  take  place  after  the 
drainage  canal  has  closed. 


CEREBRAL  TUMORS 

The  brain,  like  other  portions  of  the  body,  is  at  times  the  seat 
of  new^-growths.     Under  this  head  will  be  described  all  new^ 
formations  taking  place  within  the  skull,  and  encroaching  upon 
the  contents  of  the  cerebral  cavity, 
28 


434  MANUAL   OF   NERVOUS   DISEASES 

Etiology. — Tumors  of  the  brain  may  occur  at  any  age,  but 
the  greater  number  of  cases  occur  during  childhood  and  in 
young  adult  life.  They  are  probably  somewhat  more  frequent 
in  males  than  in  females.  In  some  cases  injury  may  be  assigned 
as  the  exciting  cause,  but  this  is  so  in  but  very  few  cases.  Some 
forms  of  cerebral  tumor  are  secondary  to  tumors  or  disease  in 
some  other  portion  of  the  body.  This  is  practically  always  the 
case  in  tubercular  growths,  in  carcinomata,  parasitic  cysts,  etc. 
Cerebral  tumors  may  also  occur  as  the  result  of  direct  extension 
of  tumors  of  the  cranial  bones,  pharynx,  orbit,  etc. 

There  is  no  satisfactory  explanation  as  to  the  origin  of  many 
forms  of  tumors,  such  as  glioma,  fibroma,  sarcoma,  etc. 

Pathology. — Tumors  may  be  single  or  multiple.  Certain 
forms  of  tumor,  such  as  sarcoma  and  glioma,  and  some  of  the 
rarer  varieties,  are  usually  single.  Other  forms,  such  as  tuber- 
culomata,  carcinomata,  syphilomata,  etc.,  are  sometimes 
multiple.  The  tumor  may  involve  almost  any  portion  of  the 
brain  substance,  the  cortex  or  the  substance  immediately 
beneath  the  cortex  being  the  point  of  origin  in  the  greatest 
number  of  cases.  The  brain-stem  and  the  cerebellum  are  in- 
volved with  about  an  equal  degree  of  frequency,  but  less  often 
do  tumors  involve  the  basilar  ganglia  and  the  surrounding 
structures.  Of  the  commoner  forms  of  brain  tumors  may  be 
mentioned  tubercle,  sarcoma,  glioma,  gliosarcoma,  and  gumma; 
less  frequently  carcinoma  occurs,  but  cysts  are  present  in  a 
large  proportion  of  cases.  Among  the  rarer  forms  of  tumor 
are  fibroma,  angioma,  lipoma,  psammoma,  osteoma,  neuro- 
fibroma, etc. 

Tuberculomata  occur  most  frequently  in  childhood,  and  are 
rarely  found  after  the  age  of  thirty.  They  may  be  single,  but 
in  a  large  proportion  of  cases  more  than  one  tumor  is  present. 
These  tumors  occur  most  frequently  in  connection  with  the 
meninges  and  large  vessels,  and  consequently  are  generally 
found  on  the  surface  of  the  brain.  They  involve  by  preference 
the  pons,  the  cerebellum,  and  the  cortex  of  the  hemispheres. 
They  do  not  destroy  the  cerebral  tissue,  but  compress  and  dis- 
place it,  and  are  frequently  surrounded  by  an  area  of  tubercular 
infiltration.    The  tumor  may  vary  in  size  from  a  small  collection 


CEREBRAL   TUMORS 


Fig.   149. — Cerebral  tumor.      Frontotemporal  lobe   (case    of  Dr.   Charles 

Bagley). 


of  miliary  tubercles,  forming  a  small  mass,  to  a  large  tumor 
which  is  hard  and  which  may  be  definitely  encapsulated. 


436  MANUAL   OF   NERVOUS   DISEASES 

Sarcoma  usually  arises  from  the  meninges,  the  periosteum  of 
the  cranial  bones,  etc.  As  a  rule,  it  is  single  and  encapsulated, 
grows  rapidly,  and  gives  rise  to  well-marked  symptoms.  These 
tumors  occur  more  frequently  in  the  cortex  of  the  hemispheres 
and  cerebellum  than  in  other  localities.  In  some  cases  a  sarcoma 
is  not  definitely  circumscribed.  These  tumors  do  not  usually 
infiltrate  the  brain  substance,  but  merely  displace  and  compress 
it,  and  when  they  are  so  situated  as  to  be  accessible  to  surgical 
intervention,  can  generally  be  successfully  removed. 

Glioma. — Gliomatous  tumors  are  third  in  frequency  of  oc- 
currence of  all  brain  tumors.  They  vary  in  size  from  that  of 
a  small  nut  to  almost  the  size  of  an  entire  hemisphere.  These 
tumors  are  usually  primary  in  type,  and  are  peculiar  to  nervous 
tissue.  They  are  not  sharply  defined  from  the  surrounding  brain 
tissue,  but  extend  by  infiltration,  and  cannot  be  removed  with- 
out completely  destroying  the  tissue  which  is  involved  (Fig.  149). 
These  tumors  are  usually  soft,  having  about  the  same  consistency 
as  the  brain  substance.  There  is  a  tendency  for  these  tumors  to 
undergo  degeneration,  so  that  cavities  filled  with  either  a  yellow- 
ish or  reddish  fluid  are  frequently  found  in  them.  Some  of 
these  tumors  are  of  a  yellow,  white,  or  gray  color,  and  at  times 
differ  very  little  in  color  from  the  normal  brain  tissue.  Gliomata 
are  made  up  mainly  of  glia-cells  and  an  intercellular  fibrillar 
network.  These  tumors  are  usually  very  vascular,  and  hemor- 
rhage into  the  growths  is  of  common  occurrence.  Glioma  may 
involve  any  portion  of  the  brain,  but  occurs  somewhat  more 
frequently  in  the  white  substance. 

Gliosarcoma. — ^This  form  of  growth  occurs  less  frequently 
than  either  glioma  or  sarcoma,  the  tumor  partaking  of  the  nature 
of  both  of  these  varieties.  It  infiltrates  and  destroys  the  brain 
tissue,  and  is  rarely  encapsulated. 

Carcinoma. — ^This  tumor  is  usually  secondary  to  carcinoma  in 
some  other  portion  of  the  body,  or  occurs  as  a  direct  extension  of 
carcinoma  of  the  orbit  or  cranial  or  facial  bones.  It  generally 
occurs  in  adults.  Carcinoma  is  a  soft,  vascular  tumor,  of 
irregular  form,  and  is  not  encapsulated.  It  is  frequently  mul- 
tiple, and  may  involve  any  portion  of  the  brain. 

Syphilitic  Tumors. — ^These  tumors  almost  always  arise  from 


CEREBRAL    TUMORS  437 

the  meninges,  and  show  a  tendency  to  spread  flatly  on  the  sur- 
face of  the  portion  of  the  brain  that  is  involved.  They  occur 
very  rarely  in  childhood,  but  are  somewhat  common  in  adult 
life.  They  are  multiple,  vary  in  size,  and  rarely  become  larger 
than  a  hazelnut.  There  is  no  tendency  on  the  part  of  these 
tumors  to  infiltrate  the  brain  tissue,  but  they  may  be  surrounded 
by  an  area  of  softened  cerebral  substance.  These  growths 
may  develop  within  the  first  few  years  or  many  years  after  a 
syphilitic  infection.  They  occur  either  as  soft,  gelatinous  masses, 
or  take  the  form  of  hard  and  more  circumscribed  tumors. 
They  occur  most  frequently  at  the  base  of  the  brain. 

Cysts  of  the  brain  arise  either  in  connection  with  tumors, 
as  the  result  of  degeneration  of  the  tumor  mass,  or  following 
hemorrhage  and  softening.  In  some  few  cases  the  cysts  are  the 
result  of  anomalies  in  development  of  the  brain.  The  contents 
of  the  cysts  are  sometimes  watery  or  serous,  and  at  other  times 
they  are  viscid  or  colloid.  In  very  rare  cases  dermoid  pysts 
develop  in  the  brain.  Cysts  are  usually  of  slow  growth,  and 
produce  symptoms  by  causing  compression  of  the  brain  tissue. 
Only  rarely  do  they  destroy  or  infiltrate  the  cerebral  tissue. 

Psammoma  occurs  almost  exclusively  in  the  meninges  and 
in  the  pineal  gland.  It  is  a  new-growth  containing  abundant, 
chalk-like  concretions,  and  develops  very  slowly.  Other  forms 
of  tumor,  such  as  fibroma,  myxoma,  lipoma,  chloroma,  etc., 
are  of  great  rarity.  As  the  result  of  the  presence  of  a  new- 
growth  within  the  cranial  cavity  an  increased  intracranial 
pressure  is  produced.  This  increased  pressure  depends  upon 
the  rapidity  of  the  tumor's  growth  and  upon  its  location. 
Tumors  under  the  tentorium  usually  produce  a  rapid  increase 
of  intracranial  pressure,  and  as  a  result  the  membranes  become 
tense  and  there  may  be  a  thinning  of  the  bone.  Tumors  may  be 
so  situated  as  to  produce  obstruction  to  the  return  circulation 
from  the  ventricles,  and  thus  bring  about  a  hydrocephalic 
condition.  There  is  usually  a  disturbance  of  the  cerebral 
circulation,  more  or  less  cerebral  edema,  and,  in  the  immediate 
neighborhood  of  the  tumor,  some  destruction  of  brain  tissue. 

Tubercular  and  syphilitic  tumors  are  usually  accompanied  by 
a  more  or  less  diffuse  meningitis.    In  a  few  cases  symptoms 


438  MANUAL   OF   NERVOUS   DISEASES 

resembling  tumor  are  due  to  aneurysm  of  the  large  vessels, 
those  at  the  base  of  the  brain  being  the  vessels  most  frequently 
affected. 

Symptoms. — Symptoms  of  tumor  of  the  brain  are  in  many 
cases  more  or  less  definite,  although  cases  do  occur  in  which 
large  tumors  have  existed  without  manifesting  symptoms 
pointing  to  the  condition.  The  symptoms  of  a  brain  tumor 
are  dependent,  first,  upon  the  presence  of  a  growth;  second, 
upon  the  situation  of  the  growth,  third,  upon  the  rapidity  of 
growth  of  the  tumor.  As  the  result  of  the  presence  of  a  cerebral 
tumor  two  sets  of  symptoms  arise — these  are  the  general  and  the 
focal.  The  general  symptoms  are  dependent  upon  the  physical 
presence  of  a  tumor,  upon  increased  intracranial  pressure,  and 
upon  the  rapidity  of  its  growth  as  well  as  upon  its  character. 
The  focal  symptoms  are  dependent  upon  the  destruction  or  irrita- 
tion of  a  limited  cerebral  area.  In  some  cases  topical  symptoms 
exist. 

General  Symptoms. — Headache  is  one  of  the  most  constant 
and  prominent  symptoms  of  a  brain  tumor.  It  may  be  absent 
or  only  very  mild  in  the  early  stages,  but  as  the  tumor  increases 
in  size  or  interferes  with  the  ventricular  circulation  the  headache 
becomes  persistent  and  reaches  a  degree  of  severity  rarely 
seen  in  other  diseases.  It  is  usually  increased  by  physical 
effort,  excitement,  mental  strain,  coughing,  etc.  It  is  generally 
diffuse,  but  in  some  cases  may  be  more  intense  in  a  localized 
area,  such  as  the  frontal  or  the  occipital  region.  The  headache 
is  often  associated  with  a  diffuse  tenderness  over  the  entire 
head  on  percussion. 

Stupor. — This  is  commonly  absent  during  the  initial  stage, 
but  cases  occur  in  which,  even  from  the  onset,  there  is  a  marked 
tendency  toward  somnolence  on  the  part  of  the  patient.  Thus 
he  goes  to  sleep  more  or  less  constantly,  sometimes  even  while 
eating.  As  a  rule  the  patient  can  be  aroused,  will  answer  a 
question,  and  then  immediately  fall  asleep  again.  Later  in  the 
disease  the  stupor  becomes  deeper  and  the  patient  is  more 
difffcult  to  arouse.  Mental  disturbances  occur  with  a  con- 
siderable degree  of  frequency;  some  individuals  become  ir- 
ritable and  impatient,  whereas  in  others  the  disposition  under- 


CEREBRAL    TUMORS  439 

goes  a  change  and  the  patient  loses  interest  and  becomes  in- 
different. Mental  dulness  and  apathy  are  frequently  very 
noticeable.  In  some  patients  peculiar  attempts  to  be  face- 
tious are  observed. 

General  Convulsions. — These  occur  in  one-half  of  the  cases  at 
some  period  of  the  disease.  The  convulsive  seizures  resemble 
epileptic  attacks,  and  if  they  occur,  as  they  sometimes  do,  before 
other  symptoms  appear,  it  is  impossible  to  distinguish  them  from 
true  epileptic  fits.  The  convulsive  seizures  are  usually  preceded 
by  some  of  the  other  general  symptoms  of  a  cerebral  tumor. 
They  vary  in  degree,  in  some  individuals  resembling  attacks  of 
petit  mal,  whereas  in  others  there  occurs  a  localized  twitching 
in  some  parts  of  the  body,  or  disturbance  of  consciousness  is 
attended  by  automatic  or  forced  movements.  Occasionally 
the  convulsive  attacks  bear  a  marked  resemblance  to  hysteric 
conditions,  or  the  general  convulsions  may  begin  with  local 
spasms. 

Vomiting. — Vomiting  is  a  common  symptom,  being  seen  with 
greatest  frequency  in  tumors  of  the  posterior  fossa.  It  often 
occurs  without  nausea  and  upon  sudden  changes  of  position. 

Vertigo.— TYiv^  occurs  somewhat  frequently,  regardless  of  the 
location  of  the  tumor.  It  is  more  apt  to  occur  in  tumors  of  the 
posterior  fossa.  The  vertigo  may  be  constant,  or  occur  at 
intervals,  and  is  frequently  brought  on  by  changes  in  position. 

Optic  Neuritis  and  Choked  Disc. — These  are  the  most  im- 
portant and  most  constant  signs  of  cerebral  tumor.  The  con- 
dition is  always  bilateral,  although  it  is  often  more  marked  in 
one  eye  than  in  the  other.  As  the  result  of  the  optic  neuritis 
or  choked  disc  optic  atrophy  eventually  develops.  A  marked 
degree  of  optic  neuritis  may  exist  without  impairment  of  the 
vision,  the  condition  being  revealed  only  upon  ophthalmoscopic 
examination  or  examination  of  the  visual  fields,  which  latter 
shows  a  constriction  and  interlacing  of  the  blue  and  red  fields. 

Pulse-rate. — The  pulse-rate  in  cerebral  tumor  is  usually  slow, 
but  may  be  irregular.  In  the  terminal  stage  of  a  tumor  the 
pulse-rate  may  become  very  rapid  and  intermittent. 

Glycosuria  and  polyuria  may  develop  during  the  course  of  a 
cerebral  tumor. 


440  MANUAL   or   NERVOUS  DISEASES 

The  general  symptoms  are  usually  gradual  in  their  onset, 
and  progress  steadily,  with  more  or  less  rapidity,  depending 
upon  the  location  and  rate  of  growth  of  the  tumor. 

Focal  Symptoms. — Focal  symptoms  may  be  absent  when  the 
tumor  is  of  very  slow  growth.  They  may  likewise  be  absent  in 
those  cases  in  which  the  tumor  is  situated  in  some  portion  of  the 
brain  with  whose  functions  we  are  not  familiar,  or  disturbance 
of  which  does  not  give  rise  to  symptoms.  The  focal  symptoms 
depend  upon  the  situation  of  the  tumor,  and  arise  as  the  result 
of  irritation  or  destruction  of  a  definite  portion  of  the  cerebral 
substance,  and  also  indirectly  owing  to  interference  with  the 
functions  of  a  portion  of  the  brain  at  a  distance  from  the  tumor. 
They  may  also  occur  as  the  result  of  interference  with  that 
portion  of  the  brain  affected  by  pressure  or  disturbance  of  its 
circulation.  The  focal  symptoms  are  gradually  progressive, 
and  are  usually  limited  in  extent. 

Focal  Symptoms  of  Tumors  of  the  Frontal  Lobe. — Tumors 
affecting  the  first  and  second  frontal  convolutions  may  give 
rise  to  change  in  character,  irritability,  mental  dulness,  rapid 
mental  fatigue,  loss  of  self-control,  and  at  times  delirium  and 
mild  dementia.  In  other  cases  there  are  marked  restlessness,  a 
tendency  to  exaggeration,  facetiousness,  change  of  character 
and  disposition,  indifference,  somnolence,  or  insomnia.  In 
some  cases  in  frontal  lobe  disease  there  is  noticed  a  disturbance 
of  the  sense  of  equilibrium.  Quite  large  tumors  of  the  frontal 
lobes  may  exist  without  giving  rise  to  any  focal  symptoms. 

Tumors  involving  the  third  and  frontal  convolutions  give 
rise  to  motor  aphasia.  If  the  left  side  of  the  brain  is  involved  in 
right-handed  individuals,  or  the  right  side  of  the  brain  in  left- 
handed  individuals,  the  speech  disturbance,  which  is  slight  at 
first,  gradually  becomes  more  and  more  marked.  At  first  the 
patient  speaks  slowly,  and  later  on  can  speak  only  with  difficulty. 
As  the  growth  advances  convulsions  may  occur,  beginning 
first  in  the  face  and  gradually  extending  to  involve  the  muscles 
of  the  upper  and  lower  extremities  on  the  side  of  the  body 
opposite  to  that  on  which  the  growth  exists. 

In  those  cases  in  which  the  tumor  originated  in  or  gradually 
involves  the  precentral  convolution  the  focal  symptoms  are 


CEREBRAL    TUMORS  44 1 

those  of  a  cortical  epilepsy.  Thus  there  occur  tonic  or  clonic 
spasms  of  the  muscles  or  convulsions,  which  may  at  first  be 
limited  in  extent,  and  gradually  extend.  As  time  goes  on 
the  spasmodic  seizures  become  more  diffuse,  and  eventually 
the  con\nalsions  are  replaced  by  paralysis.  This  paralysis  may 
at  first  be  limited  in  extent,  but  gradually  becomes  more  and 
more  extensive,  progressing  from  a  monoplegia  to  a  complete 
hemiplegia. 

The  area  first  affected  by  the  spasms  and  the  order  of  their 
progression,  and  in  later  cases  the  order  of  involvement  by  the 
paralysis,  are  the  most  important  localizing  signs.  Paresthesia, 
such  as  tingling,  frequently  precedes  and  generally  follows 
these  localized  convulsive  seizures. 

The  tendon  reflexes  are  usually  increased,  and  the  super- 
ficial reflexes  are  decreased  or  lost  on  the  side  opposite  to  the 
tumor.  Generalized  convulsive  seizures  may  occur  in  cerebral 
tumors  without  any  direct  involvement  of  the  frontal  lobe 
taking  place. 

Tumors  situated  in  the  parietal  lobe  are  not  always  attended 
by  distinctive  local  symptoms.  If  the  tumor  is  situated  in  the 
anterior  part  of  the  parietal  lobe,  paresthesia  occurs  more  or 
less  persistently,  and  may  be  attended  by  spasmodic  seizures. 
Deep  tumors  and  large  tumors  in  the  parietal  lobe  give  rise  to 
disturbance  of  sensation  upon  the  opposite  side  of  the  body, 
which  may  be  accompanied  by  ataxia.  Timiors  in  the  posterior 
part  of  the  parietal  lobe  may  give  rise  to  astereognosis.  Tumors 
in  the  lowxr  and  posterior  portion  of  the  parietal  lobe  extending 
over  into  the  anterior  portion  of  the  occipital  lobe,  if  situated 
in  the  left  hemisphere,  in  right-handed  individuals  give  rise  to 
alexia,  or  word-blindness.  Tumors  situated  in  the  depths  of 
the  parietal  lobe  may  press  upon  the  optic  radiations  and  cause 
hemianopsia. 

Localizing  Signs  of  Tumors  of  the  Occipital  Lobe. — Hemi- 
anopsia is  often  an  early  symptom  that  is  entirely  overlooked  in 
tumors  of  the  occipital  lobe.  Lesions  of  the  lateral  cortex  of 
the  left  occipital  lobe  in  right-handed  individuals,  and  of  the 
right  lateral  cortex  in  left-handed  individuals,  may  give  rise 
to  a  condition  in  which  the  individual  sees,  but  fails  to  recognize 


442  MANUAL   OF   NERVOUS   DISEASES 

the  objects  seen.  This  condition  is  known  as  mind-blindness, 
and  is  closely  allied  to  alexia. 

Tumors  of  the  temporal  lobe  involving  the  superior  temporal 
convolution  give  rise  to  a  condition  known  as  word-deafness. 
In  this  condition  the  individual  hears,  but  does  not  understand. 
Occasionally  also  tumors  of  the  temporal  lobe  may  cause  dis- 
turbance of  consciousness  or  convulsions,  which  are  ushered  in 
by  auditory  aura,  such  as  ringing  or  whistling,  or  other  sounds 
in  the  opposite  ear.  If  tumors  of  the  temporal  lobe  involve  the 
deeper  structure^,  they  will  compress  the  motor,  sensory,  and 
visual  pathways,  giving  rise  to  paralysis,  disturbance  of  sen- 
sation, and  hemianopsia.  Tumors  involving  the  apex  of  the 
temporal  lobe  may  give  rise  to  disturbances  of  taste  and  smell. 

Tumors  involving  the  island  of  Reil  give  rise  to  symptoms  by 
exerting  pressure  or  irritation  upon  the  neighboring  structures, 
thus  bringing  about  either  motor  aphasia,  if  they  press  forward; 
paralysis  of  the  opposite  half  of  the  body,  if  they  press  inward; 
or  sensory  aphasia  if  pressure  is  exerted  against  the  temporal 
lobe. 

Tumors  involving  the  optic  thalamus  cause  awkwardness  of 
movement,  disturbance  of  muscle  sense  upon  the  side  opposite 
to  the  growth,  and  sometimes  abnormal  movements,  which  may 
be  athetoid  in  character.  If  the  growth  progresses,  the  posterior 
limb  of  the  internal  capsule  becomes  compressed,  causing  motor 
paralysis,  disturbance  of  sensation,  and  hemianopsia. 

Tumors  of  the  corpus  striatum  do  not  give  rise  to  focal 
symptoms,  but  as  they  increase  in  size  they  gradually  compress 
or  destroy  the  internal  capsule,  causing  paralysis,  disturbance 
of  sensation  upon  the  opposite  side,  and  hemianopsia. 

Tumors  of  the  corpora  quadrigemina  cause  paralysis  of  the 
external  ocular  muscles,  sometimes  pupillary  paralysis,  usually 
the  oculomotor  paralysis  is  not  equal  on  both  sides,  nor  is  there 
always  involvement  of  all  the  muscles  supplied  by  these  nerves. 
Nystagmus  sometimes  occurs;  reflex  automatic  movements  of 
the  eyes  are  frequently  interfered  with.  The  gait  resembles 
that  of  cerebellar  involvement,  being  uncertain  and  staggering 
in  character.     Deafness  and  blindness  may  occur. 

Tumors  of  the  pineal  gland  may  give  rise  to  similar  symptoms, 


CEREBRAL    TUMORS  443 

causing,  in  addition,  paralysis  of  the  fourth  nerve.  In  some 
cases  tumor  in  this  region  causes  premature  development  of 
the  sexual  glands  and  exaggeration  of  the  sexual  impulses. 

Tumors  of  the  cerebellum  occasion  very  early  marked  general 
symptoms.  The  focal  symptoms  of  a  tumor  in  this  region  are 
a  staggering  gait,  with  a  tendency  to  fall  always  in  a  particular 
direction;  intense  vertigo,  nystagmus,  and  headache,  the  last 
felt  especially  in  the  occipital  region  and  in  the  neck,  and  sudden 
attacks  in  which  unilateral  convulsions,  opisthotonos,  and  tonic 
contractions  of  the  muscles  of  the  body  may  .occur.  There  is 
generally  marked  impairment  of  coordination  and  adiado- 
kokinesis,  which  is  more  marked  on  the  side  of  the  tumor. 
Hypotonia  and  ataxia  may  also  be  caused  by  cerebellar  tumors. 
In  some  cases  abnormal  positions  of  the  head  and  body  occur. 
If  the  tumor  presses  downward,  the  pons,  medulla,  and  cranial 
nerves  will  be  affected.  Headache,  vomiting,  and  vertigo  are 
frequently  intensified  or  brought  about  by  changes  in  the  position 
of  the  head. 

Tumors  of  the  cerebellopontine  angle  give  rise  to  symptoms 
by  compressing  the  pons  or  medulla,  by  compressing  or  irritating 
the  cerebellar  peduncles  or  cerebellum,  and  by  compressing  or 
irritating  the  cranial  nerves  situated  in  this  region.  ,  As  the 
result  of  compression  of  the  pons  or  medulla,  there  is  a  paralysis 
or  weakness  of  a  spastic  nature  in  the  arm  and  leg  on  the  side 
of  the  body  opposite  to  the  tumor.  Delay  in  the  transmission 
of  sensory  impulses  or  anesthesia  may  also  exist  on  the  opposite 
side  of  the  body  (Fig.  150). 

The  symptoms  due  to  irritation  or  compression  of  the  cere- 
bellum or  cerebellar  peduncles  are:  a  staggering  gait,  tending 
uniformly  to  go  to  one  side,  incoordination,  sometimes  ataxia, 
and  adiadokokinesis,  which  is  either  limited  or  marked  on  the 
side  opposite  to  that  on  which  the  tumor  is  situated. 

The  symptoms  due  to  irritation  or  compression  of  the  cranial 
nerves  are:  Intense  pain  of  a  neuralgic  character  in  the  distri- 
bution of  the  fifth  nerve ;  this  is  usually  followed  by  disturbance 
or  loss  of  sensation  along  the  course  of  this  nerve.  In  some  cases 
the  neuralgic  attacks  do  not  precede  the  loss  of  sensation.  In 
addition,  there  are  paralysis  or  weakness  of  the  external  rectus 


444 


MANUAL   OF   NERVOUS   DISEASES 


muscle;  weakness  followed  by  paralysis  of  the  muscles  of  ex- 
pression; attacks  of  pain  in  the  ear,  tinnitus,  and  deafness  at- 
tended by  vertigo;  disturbance  of  swallowing;  regurgitation  of 
food  through  the  nose ;  unilateral  laryngeal  paralysis ;  paralysis 
of  one  side  of  the  tongue,  causing  defective  articulation,  etc. 


Fig.  150. — Brain  showing  tumor  in  right  cerebellopontile  angle. 


Cranial  nerve  manifestations,  when  they  occur,  manifest 
themselves  on  the  side  of  the  body  corresponding  to  that  on 
which  the  tumor  is  situated. 

Tumor  of  the  cerebral  peduncles  is  characterized  by  paralysis 
of  the  third  nerve  on  the  same  side  as  the  tumor,  and  weakness 
or  paralysis  of  a  spastic  type  upon  the  opposite  side  of  the  body. 
Tumors  in  this  region  also  frequently  give  rise  to  abnormalities 


CEREBRAL    TUMORS  445 

of  movement,  causing  tremors,  which  may  be  intentional  in 
character  or  resemble  the  tremor  of  paralysis  agitans. 

Oculomotor  paralysis,  tremor,  and  hemiplegia  upon  the  side 
of  the  body  opposite  to  the  oculomotor  paralysis  constitute 
what  is  known  as  Benedikt's  syndrome. 

Tumors  of  the  third  ventricle  are  especially  prone  to  cause 
drowsiness  and  a  tendency  to  fall  into  a  comatose  condition. 
Tumors  of  the  pons  cause  paralysis  of  the  third,  fifth,  or  sixth 
nerves,  with  pain,  disturbance  of  sensation,  anesthesia,  trophic 
disorders  in  the  distribution  of  the  fifth  nerve,  sometimes 
grinding  of  the  teeth  on  the  side  of  the  tumor,  with  weakness 
or  paralysis  of  a  spastic  nature  upon  the  opposite  side  of  the 
body.  Tumors  in  the  medulla  cause  weakness  or  paralysis  in 
the  distribution  of  the  ninth,  tenth,  eleventh,  or  twelfth  ner\xs 
on  the  side  with  the  tumor,  together  with  weakness  or  paralysis 
of  a  spastic  type  upon  the  opposite  side  of  the  body. 

In  those  cases  in  which  the  tumor  is  sufi&ciently  large  to  com- 
press the  deeper  structures  of  the  pons,  crura,  or  medulla, 
sensory  disturbances  may  be  added  to  those  of  the  motor 
type,  and  if  the  tumor  increases  in  size,  so  as  to  involve  these 
structures  more  extensively,  weakness  and  paralysis  finally 
attack  the  unaffected  side  of  the  body. 

Tumors  occurring  in  the  h^-pophysis  cerebri  give  rise  to  three 
sets  of  symptoms:  First,  the  general  symptoms  of  an  intra- 
cranial tumor ;  second,  those  due  to  interference  with  the  internal 
secretions  of  this  gland;  and  third,  symptoms  due  to  involvement 
of  the  structures  in  the  immediate  vicinity  of  the  gland. 

The  first  set  of  symptoms  has  been  previously  enumerated. 
The  second  set  of  symptoms  includes  gigantism  or  acromegaly, 
if  the  gland  is  stimulated  to  increased  activity;  adiposity,  with 
increased  tolerance  for  carbohydrates,  with  or  without  genital 
h\^oplasia  if  the  glandular  secretion  is  diminished  or  interfered 
with.  The  third  set  of  s\Tnptoms  is  the  result  of  pressure  or 
destruction  of  the  surrounding  structures;  thus  if  the  optic 
tracts  or  chiasm  are  pressed  upon  or  destroyed,  bitemporal 
hemianopsia  occurs,  and  frequently  the  third  and  fourth  ner^'es 
are  affected;  exophthalmos  may  occur  if  the  cavernous  sinus  is 
pressed  upon  or  if  the  tumor  invades  the  orbit;  if  pressure  is  made 


446  MANUAL   OF   NERVOUS   DISEASES 

on  the  crura,  hemiplegia  will  occur,  and  in  some  cases  the  sense 
of  smell  is  lost. 

Course. — ^A  cerebral  tumor  may  exist  for  a  considerable 
length  of  time  without  giving  rise  to  any  definite  symptoms.  It 
may  manifest  its  presence  more  or  less  suddenly,  particularly 
in  gliomatous  tumors,  the  first  evidence  of  its  existence  being  a 
sudden  apoplectic  seizure  due  to  hemorrhage  into  the  growth. 
Other  tumors  manifest  themselves  by  symptoms  pointing  to 
irritation  of  a  localized  cerebral  area,  whereas  others  first  give 
rise  to  general  cerebral  symptoms.  As  time  goes  on,  in  some 
cases  more  rapidly  than  in  others,  there  is  a  gradual  increase 
and  progression  of  symptoms.  The  disease  may  run  a  more  or 
less  rapid  course,  a  fatal  termination  occurring  within  six  or 
eight  months,  but  the  usual  duration  is  about  three  years. 
Some  tumors  are  present  for  many  years,  and  in  some  cases 
the  growth  is  discovered  only  after  death  from  some  inter- 
current disease.  The  location  and  character  of  the  growth  in- 
fluence the  rapidity  with  which  the  symptoms  develop,  and 
upon  these  is  dependent  the  duration  of  life  after  the  first 
symptoms  have  manifested  themselves.  Tubercular  growths, 
glioma,  and  carcinoma  usually  develop  rapidly;  sarcoma, 
syphilitic  growths,  and  fibroma  may  develop  more  slowly; 
on  the  other  hand,  tubercular  growths  may  develop  very  slowly 
and  syphilitic  growths  very  rapidly.  Tumors  situated  in  the 
posterior  cranial  fossa  and  those  involving  the  basilar  ganglia 
and  brain-stem  give  rise  to  a  more  rapid  development  of  symp- 
toms. Growths  involving  the  medulla  usually  cause  a  rapid 
fatal  termination. 

Prognosis. — The  prognosis  of  cerebral  tumors  depends  to  a 
great  extent  upon  the  character  of  the  growth,  the  possibility 
of  locating  it,  its  accessibility  to  surgical  intervention,  and  upon 
the  patient's  general  physical  condition  and  w^hether  the  diag- 
nosis is  made  early  or  late. 

Gliomatous  tumors,  carcinoma,  and  diffuse  sarcoma,  owing  to 
the  fact  that  they  cannot  be  entirely  eradicated,  are  not  amenable 
to  surgical  treatment,  and  consequently  the  outlook  in  these 
tumors  is  hopeless.  Encapsulated  sarcoma,  when  situated  in 
a  position  that  is  surgically  accessible,  may  be  removed,  with 


CEREBRAL    TUMORS  447 

more  or  less  complete  recovery,  this  depending  upon  the  amount 
of  brain  tissue  that  has  been  destroyed  at  the  time  of  the  opera- 
tion. Tubercular  growths  are  sometimes  arrested  spontaneously. 
As  a  rule,  when  an  effort  is  made  to  remove  them  surgically 
there  is  subsequent  infection  of  the  meninges,  with  recurrence 
of  the  growth  or  the  development  of  a  tubercular  meningitis. 

Syphilitic  growths  are  generally  amenable  to  antisyphilitic 
treatment.  Cysts,  if  situated  in  operable  areas,  and  if  they 
are  not  secondary  to  glioma,  can  very  frequently  be  removed 
by  drainage  and  excision  of  the  cyst-wall. 

Diagnosis. — When  the  presence  of  a  cerebral  tumor  is  sus- 
pected, it  is  necessary,  in  order  to  confirm  the  diagnosis,  to 
exclude  nephritis,  meningitis,  general  paresis,  cerebral  abscess, 
and  lead-poisoning. 

Tumor  is  differentiated  from  nephritis  by  careful  examination 
of  the  urine,  the  variability  of  symptoms  in  nephritis,  the  pres- 
ence of  a  neuroretinitis  rather  than  an  optic  neuritis,  usually  rapid 
pulse  with  high  arterial  tension  and  the  onset  of  the  symptoms, 
which  may  be  either  very  rapid  or  extend  over  a  period  of  years. 
In  tumor  the  onset  of  the  symptoms  is  gradual,  and  the  condition 
progresses  over  a  period  of  from  a  few  months  to  one  or  tw^o 
years;  there  is  more  apt  to  be  an  optic  neuritis  than  a  neuro- 
retinitis, and  the  urine  may  be  negative,  the  pulse  slow^,  the 
blood-pressure  not  necessarily  high,  etc. 

From  meningitis  tumor  is  distinguished  by  the  absence  of 
temperature  in  the  latter  condition,  by  the  rapid,  irregular  pulse 
in  meningitis,  the  absence  of  cervical  rigidity  in  tumor,  the 
presence  of  leukocytosis  and  the  more  acute  onset  in  meningitis, 
and  by  the  results  of  examination  of  the  cerebrospinal  fluid. 

Cerebral  tumor  is  differentiated  from  general  paresis  by  the 
presence,  in  the  latter,  of  optic  atrophy  rather  than  optic  neuritis, 
pupillary  disturbances  which  are  bilateral,  the  examination  of 
the  cerebrospinal  fluid  yielding  a  positive  Wassermann  reaction, 
with  an  increased  cell-count,  and  by  the  presence  of  disturbances 
of  memory  and  of  speech  which  are  characteristic  of  paresis. 

From  a  slowly  progressive  cerebral  abscess  tumor  is  sometimes 
distinguished  only  wdth  great  difficulty.  In  these  cases  the 
history  of  a  possible  focus  of  origin  of  the  abscess  is  very  im- 


448  MANUAL  OF  NERVOUS  DISEASES 

portant.  As  a  rule,  the  progression  of  symptoms  is  accompanied 
by  marked  temperature  disturbances;  leukocytosis  is  usually 
present,  and  there  are  elevations  of  temperature  with  exacerba- 
tion of  symptoms  and  a  subnormal  temperature  in  the  intervals. 

From  lead-poisoning  tumor  is  differentiated  by  the  examination 
of  the  blood,  the  history  of  exposure  to  lead-poisoning,  and  the 
intermittent  progress  of  the  symptoms. 

If  the  presence  of  a  cerebral  tumor  has  been  positively  deter- 
mined,— and  this  can  usually  be  done  in  about  85  per  cent,  of 
the  cases, — it  is  necessary  to  locate  the  tumor,  and  to  decide 
whether  or  not  it  can  be  removed.  The  character  of  the  growth 
must  also  be  determined,  and  whether  or  not  it  is  single  or 
multiple.  The  location  of  the  growth  is  determined  from  the 
focal  symptoms  and  the  history  of  the  progress  of  the  general 
and  focal  manifestations.  In  some  cases  in  which  the  growth 
is  on  or  near  the  surface  of  the  brain,  the  bone  over  the  growth 
may  be  eroded  and  the  tumor  may  be  palpable.  In  some  few 
cases  there  are  pain  and  tenderness  on  percussion  on  the  surface 
over  the  growth.  Whether  or  not  the  tumor  is  removable 
surgically  is  dependent  upon  the  location  and  the  character  of 
the  growth,  and  on  whether  it  is  single  or  multiple.  Only  those 
growths  that  displace  or  compress,  but  do  not  infiltrate,  the 
brain  tissue  are  surgically  removable.  Multiple  growths  and 
very  extensive  diffuse  growths  cannot  be  removed.  Tumors 
involving  the  ventricles,  the  basilar  ganglia,  or  other  portions 
of  the  brain  not  accessible  to  surgical  intervention  are  inoperable. 
The  character  of  the  growth  can  be  diagnosed  only  approxi- 
mately before  operating:  one  must  take  into  consideration  the 
age  of  the  patient,  the  progress  of  the  symptoms,  the  presence 
of  syphilis,  tuberculosis,  or  malignant  growths  in  other  portions 
of  the  body,  trauma,  etc. 

In  general,  the  diagnosis  of  tumor  of  the  brain  rests  upon  a 
history  of  more  or  less  persistent  headache,  vomiting,  and  vertigo, 
extending  over  a  considerable  period,  and  the  presence  of  choked 
disc,  and  in  some  cases  of  distinctly  progressive  symptoms 
pointing  to  irritation  or  destruction  of  a  local  cerebral  area. 
The  examination  of  the  cerebrospinal  fluid,  and  the  general 
physical  examination  of  the  individual,  and  in  some  cases  in 


PARALYTIC   DEMENTIA  449 

which  the  tumor  is  accompanied  by  bone  changes,  such  as  tumors 
involving  the  sella  turcica,  a  radiographic  examination,  are  all 
aids  to  correct  diagnosis. 

Treatment. — In  all  cases  in  which  there  is  a  progressive  optic 
neuritis  a  subtemporal  decompression  operation  should  be 
performed.  In  those  cases  in  which  syphilis  is  suspected  as  the 
underlying  cause,  a  thorough  course  of  antisyphilitic  treat- 
ment should  be  instituted.  The  patient's  general  physical 
condition  should  receive  attention.  Pain  should  be  relieved  by 
the  administration  of  anodynes.  Vomiting  and  convulsions 
are  usually  best  treated  by  rest  and  the  adminstration  of  the 
bromids.  A  light  nutritious  diet  should  be  ordered,  and  tonics 
should  be  given  to  conserve  the  patient's  general  strength. 
In  those  cases  in  which  the  growlh  is  localized  and  is  situated  in 
a  region  of  the  brain  that  is  accessible  surgically  an  effort  should 
be  made  to  effect  its  removal.  In  the  hands  of  those  who  are 
specially  trained  in  neural  surgery  operative  intervention  is  a 
comparatively  safe  procedure. 

PARALYTIC   DEMENTIA   (GENERAL  PARESIS; 
GENERAL  PARALYSIS   OF  THE  INSANE) 

This  is  a  disease  of  the  brain  characterized  chiefly  by  progres- 
sive weakness  of  the  mind  and  of  the  body. 

Etiology. — Heredity,  intellectual  overwork,  trauma,  worry, 
chronic  poisoning  by  alcohol,  etc.,  are  all  important  factors  in 
the  production  of  this  disease,  but  the  principal  underlying 
cause  in  practically  all  cases  is  syphilis.  Males  are  more  fre- 
quently affected  than  females.  The  disease  usually  manifests 
itself  between  the  thirtieth  and  the  fiftieth  year,  and  occurs 
only  rarely  after  the  sixtieth  year.  Frequently  the  condition 
develops  in  the  very  young,  when  it  is  believed  to  be  due  to 
hereditary  syphilis.  The  disease  is  more  prevalent  in  large 
cities  than  in  rural  communities,  and  is  also  more  apt  to  aft'ect 
those  engaged  in  intellectual  pursuits  or  those  whose  occupa- 
tion requires  constant  mental  alertness  than  those  w^ho  are 
not  exposed  to  mental  strain.  In  addition  to  syphilis,  other 
chronic  toxemias,  such  as  alcohol  and  tobacco,  and  gastro- 
29 


450  MANUAL   OF   NERVOUS   DISEASES 

intestinal  disturbances,  occupy  an  important  position  in 
the  production  of  the  condition.  Trauma,  mental  strain, 
worry,  physical  fatigue,  acute  intoxication,  physical  and  sexual 
excesses,  exhausting  diseases,  emotional  disturbances,  such  as 
fright,  joy,  etc.,  are  also  frequent  etiologic  factors. 

Pathology. — The  pathologic  changes  occur  mainly  in  the 
brain.  The  spinal  cord  is  usually  involved  also,  and  sooner  or 
later  pathologic  changes  appear  in  practically  all  the  organs  of 
the  body.  The  brain  is  generally  decreased  in  size;  the  convolu- 
tions appear  atrophied;  the  fissures  are  wider  and  deeper. 
Atrophy  affects  especially  the  frontal  lobe,  although  the  entire 
brain  may  be  affected.  The  pia  mater  is  generally  firmly  ad- 
herent to  the  brain,  and  cannot  be  removed  without  particles 
of  the  cortical  substance  adhering  to  it.  The  meninges  are 
thickened  and  often  opaque;  the  ventricles  are  somewhat  di- 
lated; the  endothelial  linings  show  granular  and  inflammatory 
changes;  the  arteries  exhibit  sclerotic  changes;  the  cerebrospinal 
fluid  is  generally  increased  in  amount,  and  contains  a  larger 
number  of  cellular  constituents  than  normally.  Microscopically 
there  is  seen  a  degeneration  and  atrophy  of  the  cells  and  fibers 
of  the  cerebral  cortex  which  is  exceedingly  diffuse  in  distribu- 
tion. Degenerative  changes  are  also  discovered  in  the  basilar 
ganglia,  brain  axis,  and  in  the  spinal  cord.  Gray  degeneration 
of  the  optic  nerve  and  sometimes  of  the  other  cranial  nerves 
occasionally  occurs.  There  is  a  proliferation  of  glial  tissue 
throughout  the  cortex,  being  most  marked  around  the  blood- 
vessels. The  various  organs  of  the  body,  such  as  the  liver, 
kidney,  heart,  etc.,  show  changes  of  a  chronic  inflammatory 
nature. 

Sjrmptoms. — ^This  disease  develops  more  or  less  insidiously, 
and  in  the  early  stages  is  characterized  by  symptoms  that  are 
more  or  less  indefinite  in  character.  During  this  period  the  pa- 
tient may  be  sleepless  and  irritable,  and  complain  of  vague 
pain  and  inability  to  concentrate  the  thoughts  or  to  carry  on 
prolonged  mental  work.  There  may  be  digestive  disturbances, 
loss  of  appetite,  depression,  headache,  and  a  general  feeling  of 
illness,  or  these  symptoms  may  be  absent  and  in  their  stead -it 
may  be  noticed  that  the  individual's  memory  is  inaccurate. 


PARALYTIC    DEMENTIA  45 1 

and  he  may  manifest  a  peculiarity  of  speech;  in  writing,  words 
are  frequently  misspelled,  syllables  or  entire  words  being  omitted, 
or  there  may  be  a  reduplication  of  words  or  syllables.  There  is 
frequently  observed,  early  in  the  disease,  indifference  to  the 
higher  sentiments,  lapses  from  the  proprieties,  and  disregard  or 
failure  of  interest  in  important  matters.  In  other  cases  the 
patient  becomes  depressed  and  indifferent,  easily  upset,  displays 
weakness  of  judgment,  and  is  unduly  susceptible  to  external 
influences.  Other  patients  become  active,  restless,  egotistical, 
and  easily  excited,  and  show  a  marked  tendency  toward  exag- 
geration and  extravagance.  These  patients  frequently  display 
tendencies  to  sexual  and  alcoholic  excesses.  Their  judgment  is 
poor,  the  higher  feelings  become  blunted,  and  they  exhibit  a 
marked  tendency  to  disregard  the  rights  of  others.  In  the  early 
stages  the  disease  is  characterized  principally  by  vague  subjec- 
tive physical  symptoms  and  by  gradual  weakness  of  the  mental 
powers;  judgment  is  interfered  with,  and  the  finer  feelings  be- 
come dulled.  There  is  a  loss  or  decrease  of  self -consciousness, 
and  the  conduct  becomes  less  restrained.  Usually  there  are 
physical  objective  signs  that  enable  one  to  suspect  the  under- 
lying condition ;  for  example,  weakness  or  slight  paralysis  of  one 
side  of  the  face;  transitory  ocular  paralysis;  unequal  pupils  or 
pupils  that  are  abnormally  contracted  or  fail  to  react  to  light. 
The  tendon  reflexes  may  be  markedly  diminished,  lost,  or  in- 
creased, and  there  may  be  fibrillary  tremor  of  the  facial  muscles 
or  the  tongue  upon  voluntary  movement,  slight  diflSculty  in 
articulation,  and  epileptiform  or  apoplectiform  attacks.  Ex- 
amination of  the  blood  and  cerebrospinal  fluid,  even  at  this 
stage,  will  in  the  vast  majority  of  cases  reveal  evidence  of  the 
presence  of  a  syphilitic  infection  (Fig.  151). 

As  the  disease  progresses,  it  assumes  one  of  three  types:  the 
demented  type,  the  depressed,  or  the  exalted  type.  In  any 
one  of  these  three  types  hallucinations  may  be  present;  in  the 
demented  t}'pe  there  is  a  progressive  failure  of  memory  for 
both  remote  and  recent  events,  for  the  passage  of  time,  and  the 
patient  may  fail  to  recognize  himself  in  his  surroundings  and 
frequently  mistake  the  personality  of  those  with  whom  he  comes 
into  contact.    Often  he  becomes  indifferent  to  his  surroundings, 


452 


MANUAL   OF  NERVOUS   DISEASES 


but  at  times  there  may  be  frequent  outbursts  of  anger  and  irri- 
tability. In  the  depressed  type  the  individual  becomes  des- 
pondent, pessimistic,  and  is  unable  to  reach  a  conclusion.  He 
is  frequently  apprehensive  of  his  own  condition.  Later  his 
ideas  are  of  a  self-accusatory  character,  his  judgment  becomes 
weakened,  and  suicidal  attempts  are  common.  In  addition  to 
the  depressive  features,  these  patients  show  disturbances  of 
memory,  failure  of  iudgment,  and  moral  and  ethical  indiffer- 


Fig.  151. — General  paresis,  early  stage  (Bay  View  Hospital). 

ence.  In  the  exalted  type  the  patient  becomes  expansive, 
egotistical,  and  restless,  and  rapid  changes  of  emotion,  from 
marked  irritability  and  anger  to  happiness  and  good-fellowship, 
occur.  These  patients  are  especially  prone  to  sexual  and  alco- 
holic excesses.  As  the  result  of  their  weakened  judgment  they 
frequently  undertake  all  sorts  of  absurd  and  senseless  schemes. 
In  conjunction  with  these  mental  manifestations  hallucina- 
tions may  occur. 
The  second  stage  is  characterized  by  progressive  failure  of 


PARALYTIC   DEMENTIA  453 

memory,  increased  weakness  of  judgment,  emotional  dis- 
turbances, and  marked  obtunding  of  the  ethical,  esthetic,  and 
moral  feelings.  Delusions  of  a  depressive  type  may  also  be 
present.  The  objective  physical  signs  of  the  first  stage  are 
intensified.  The  speech  disturbances  are  characteristic — there 
is  a  duplication  or  elision  of  syllables  and  letters;  this  is  well 
shown  in  the  efforts  to  pronounce  test  phrases,  such  as  "Third 
German  riding  artillery  brigade,"  "Massachusetts,"  "Metho- 
dist-Episcopal," "immovable,"  etc.  Artillery  is  frequently 
pronounced  artilry,  or  artillilery,  brigade,  bigrad,  etc. 

As  the  disease  progresses  the  difficulty  in  pronouncing  words 
and  in  remembering  phrases  increases.  The  speech  is  usually 
attended  by  a  marked  fibrillary  tremor  of  the  face  and  tongue. 
The  handwriting  also  shows  marked  disturbances — words  are 
omitted,  words,  syllables,  or  even  entire  sentences  are  repeated, 
and  very  frequently  there  is  a  fine  tremor  of  the  fingers,  ac- 
companied by  a  coarse  tremor  of  the  hands  which  evidences 
itself  upon  voluntary  movement. 

In  at  least  95  per  cent,  of  cases  pupillar}^  disturbances  are 
present.  The  Argyll  Robertson  pupil  is  present  in  most  cases, 
and  there  are  also  frequently  inequality  of  the  pupils,  extreme 
pupillary  contraction,  irregularity  of  pupillary  outline,  and 
sluggish  pupillary  reaction  to  light. 

The  deep  reflexes  are  generally  increased.  In  those  cases  in 
which  the  spinal  symptoms  are  marked  the  deep  reflexes  may 
be  diminished  or  lost.  There  may  be  marked  difference  of  the 
deep  reflex  responses  of  the  two  sides  of  the  body.  As  the  dis- 
ease progresses  there  is  a  disturbance  in  the  control  of  the 
rectal  and  vesical  reflexes. 

Sooner  or  later  motor  disturbances  occur.  Apoplectiform  or 
epileptiform  seizures  or  progressive  weakness  develop,  and 
attacks  of  unconsciousness  and  of  vertigo  are  also  frequently 
observed.  Weakness  of  intellect  and  transitory  or  permanent 
cranial  nerve  paralysis  occur  in  both  the  first  and  the  second 
stage  of  the  disease.  In  the  early  stages  of  the  affection  there 
is  often  a  loss  of  weight,  but  in  the  second  stage,  when  the 
dementia  is  once  under  way,  there  is  often  a  gaia  of  weight. 
Hallucinations  and  illusions  frequently  occur  ia  the  second 


454  MANUAL   OF   NERVOUS   DISEASES 

stage  of  the  disease,  and  bear  a  distinct  relation  to  the  emo- 
tional state.  In  the  second  stage  of  the  disease  remissions 
may  occur,  and  an  apparent  improvement  in  the  patient's 
mental  and  physical  condition  take  place.  In  some  cases  the 
improvement  attains  so  marked  a  degree  that  it  is  almost  im- 
possible to  discover  evidences  of  mental  disease.  The  physical 
signs,  of  course,  remain  permanently  present,  and  sooner  or 
later  there  is  a  recurrence  of  the  symptoms,  or  without  a  remis- 
sion in  the  symptoms  the  patient  may  enter  into  the  third  or 
terminal  stage. 

In  the  third  stage  the  evidence  of  dementia  becomes  more 
marked,  and  the  speech  disturbance  is  more  pronounced,  until 
finally  speech  becomes  a  mere  mumbling  of  sounds.  Progres- 
sive inanition  occurs,  trophic  disorders  manifest  themselves, 
and  the  individual  becomes  neglectful  in  his  habits  and  finally 
helpless  and  bedridden.  Grinding  of  the  teeth  becomes  marked, 
and  there  is  difficulty  in  swallowing.  Attacks  of  coughing  and 
choking  occur,  and  finally  death  follows  as  the  result  of  pneu- 
monia, septicemia,  or  exhaustion.  Some  patients  die  before 
this  stage  is  reached,  the  fatal  termination  being  due  to  some 
intercurrent  condition  or  to  apoplectiform  or  epileptiform 
attacks. 

Course. — ^This  disease  is  usually  insidious  in  its  onset,  ex- 
isting frequently  for  weeks  or  months  before  it  is  recognized. 
It  runs  a  slowly  progressive  course.  At  times  there  are  acute 
exacerbations  of  symptoms,  these  being  particularly  apt  to 
occur  after  a  paralytic  attack.  Remissions  not  uncommonly 
occur  with  an  almost  complete  disappearance  of  the  subjective 
symptoms.  These  remissions  may  last  for  from  a  few  days  to 
six  months,  rarely  longer. 

In  the  greater  number  of  cases  the  disease  runs  its  course 
within  three  or  four  years;  in  exceptional  cases  death  occurs 
within  a  few  months,  and  in  very  few  cases  the  illness  may 
last  for  ten  years  or  more.  Those  cases  showing  dementia  and 
those  in  which  spinal  symptoms  are  marked  usually  run  a 
slower  course. 

Prognosis. — Prognosis  is  extremely  unfavorable.  Recently 
a  few  cases  of  general  paralysis  have  been  reported  in  which 


PARALYTIC    DEMENTIA  455 

cure  followed  the  use  of  intravenous  and  intraspinous  medica- 
tion. As  yet,  however,  the  number  of  patients  so  treated  has 
not  been  sufficiently  large  to  warrant  a  statement  as  to  the 
efficiency  of  this  form  of  treatment.  Even  if  it  were  capable 
of  arresting  the  progress  of  the  disease,  it  cannot  restore  the 
brain  tissue  that  has  already  been  destroyed.  At  best,  one 
can  expect  good  results  only  in  those  cases  that  are  diagnosed 
before  pronounced  symptoms  have  occurred. 

Diagnosis. — In  the  early  stages  of  the  disease  general 
paresis  may  be  confused  with  neurasthenia,  cerebral  arterio- 
sclerosis, and  cerebrospinal  syphilis. 

Neurasthenia  General  Paresis 

Pupillary  Disturbances 
Pupils   may  be  dilated   or   con-  May   be   dilated   or   contracted, 

tracted,  but  react  to  light  and  are  react  sluggishly  or  not  at  all  to 
not  irregular  in  outline.  light,  and  may  be  irregular  in  out- 

line. 

Deep  Reflexes 
Usually  active  and  equal.  May    be    increased,    decreased, 

lost,  or  unequal. 

Tremor 
Fine  rapid  tremor  of  the  fingers  Fine  fibrillary  tremors  involving 

and  hands.  the  trunk  and  facial  muscles. 

Memory 
Patient  complains  of  disturbance  Patient  usually  shows  true  de- 

of  memory,  which  really  does  not        fects  of  memory, 
exist. 

Complaints 

Complains    at    length    of    many  Frequently  has  no  cgmplaint;  at 

physical    and    mental    symptoms,         times  there  is  marked  variability 

and  is  apprehensive  of  the  presence        in  his  complaint;   often  the  emo- 

of  organic  physical  disease.  tional  tone  is  not  in  accord  mth 

the  complaint. 

Actions 

No   changes   in   the   moral   and  A    decrease    of    the    ftner    and 

higher  feelings.  moral   feelings,    evidenced   by   ac- 

tions that  are  not  in  accord  mth 
the  previous  life  of  the  patient. 

Age 
The  first  attack  occurs  more  fre-  Occurs  more  frequently  after  the 

quently  before  the  thirtieth  year.  thirtieth  year. 


456  MANUAL   OF  NERVOUS   DISEASES 

General  Arteriosclerosis  General  Paresis 

Age 

Generally  after  the  fiftieth  year.  Generally  between  the  thirtieth 

and  fortieth  year. 

Pupillary  Disturbances 
Pupils  may  be  contracted  or  di-  Pupils  contracted  or  dilated,  un- 

lated,  unequal,  but  react  to  light.  equal  or  irregular,  fail  to  react  to 

light. 

Tremor 
Involves     the     extremities     and  Fine  fibrillary  tremors  of  facial 

head;  is  intentional  in  character.  muscles,  involving  also  the  trunk. 

Memory 
Disturbed  more  for  recent  events.  Diffuse  disturbance  of  memory, 

and  only  in  terminal  stage  for  re-        both  remote  and  recent, 
mote  events. 

Examination  of  the  Cerebrospinal  Fluid 

Negative  Wassermann  and  cell  Positive  Wassermann,  increased 

count.  cell   count,    and   positive   globulin 

reaction,  etc. 

Cerebrospinal  Syphilis  General  Paresis 

Headache 
More  or  less  severe  and  constant.  Infrequent  and  rarely  persistent. 

History  of  Syphilitic  Infection 
Of  recent  date.  Five  to  twenty  years  preceding. 

Pupillary  Disturbance 

May  be  absent,  or  present  in  one  Argyll  Robertson  pupil. 

eye;  or  there  may  be  immobility 
to  both  light  and  accommodation. 

Cranial  Nerve  Paralysis 
Frequent,  and  of  rapid  onset.  Infrequent;  of  slower  onset,  and 

transitory. 

Speech  Disturbance 

Usually  not  present,  or  if  present,    ■        Speech     disturbance     generally 
of  an  aphasic  character.  present,  with  a  characteristic   eli- 

sion or  reduplication  of  syllables 
and  words. 

Mental  State 

Stuporous  states  frequently  pres-  Rarely  present, 

ent. 

Portion  of  Brain  Involved 

Symptoms  point  more  to  basilar  Symptoms  point  chiefly  to  corti- 

involvement.  cal  involvement. 


PARALYTIC   DEMENTIA  457 

The  diagnosis  of  general  paresis,  as  a  rule,  does  not  present 
much  difficulty  if  one  takes  into  consideration  the  change  of 
character  and  of  disposition  of  the  individual,  together  with 
the  physical  signs  of  the  disease. 

Some  cases  of  general  paresis  occur,  however,  which,  in  the 
early  stages,  present  typical  neurasthenic  symptoms,  and  in 
which  there  is  an  absence  of  the  physical  signs.  In  these  indi- 
viduals a  mistaken  diagnosis  may  be  made,  the  true  state  of 
affairs  not  being  revealed  until  a  subsequent  period,  when  the 
patient's  actions  or  the  discovery  of  physical  signs  clear  up  the 
diagnosis.  One  should  always  look  with  suspicion  on  previously 
healthy  individuals  that  present  neurasthenic  symptoms  for  the 
first  time  after  the  age  of  thirty-five  or  forty.  There  also  occur 
cases  in  which  the  differentiation  between  cerebrospinal  syph- 
ilis and  general  paresis  is  absolutely  impossible,  the  subsequent 
course  of  the  disease  and  the  response  to  treatment  being  the 
only  true  guide  to  correct  diagnosis. 

At  times  paresis  may  first  manifest  itself  by  a  sudden  maniacal 
outbreak,  and  under  these  conditions  it  must  be  differentiated 
from  the  excited  phase  of  some  other  form  of  mental  disease. 
In  these  cases  the  history  is  important.  The  excitement  is 
rarely  so  marked  or  so  sudden  in  other  mental  disorders  as  it  is 
in  paresis,  and  the  presence  of  the  physical  signs  of  paresis  and 
the  examination  of  the  cerebrospinal  fluid  will  usually  enable 
one  to  reach  a  correct  conclusion.  If  paresis  manifests  itself 
first  in  apoplectic  or  epileptic  attacks,  difficulty  may  be  ex- 
perienced, first,  in  differentiating  the  patient's  condition  from 
vascular  cerebral  disease,  epilepsy,  and  other  organic  cerebral 
diseases.  Under  these  conditions  the  subsequent  history  of 
a  gradually  progressive  disease,  the  presence  of  physical  signs 
of  paresis,  the  examination  of  the  cerebrospinal  fluid,  and  a 
history  of  the  preceding  physical  and  general  state  of  the  pa- 
tient will  confirm  the  diagnosis. 

Treatment. — ^This  is  largely  prophylactic,  and  consists  of 
proper  and  prompt  treatment  of  syphilitic  infection.  In  those 
who  have  had  this  infection,  the  mode  of  life  should  be  as  com- 
paratively free  as  possible  from  mental  and  physical  strains, 
and  excesses  of  all  kinds  should  be  avoided. 

As  soon  as  the  diagnosis  is  made,  the  patient's  family  should 


458  MANUAL   OF   NERVOUS   DISEASES 

be  notified  of  the  danger  that  threatens  the  patient  because  of 
his  disturbance  of  judgment,  the  likelihood  of  his  squandering 
or  wasting  his  means,  and  the  possibility  of  trouble  because  of 
his  changed  conduct.  The  individual  should  be  placed  under 
the  necessary  legal  restrictions,  and  should  be  guarded  and  pro- 
tected from  harm.  In  most  cases  committal  to  an  institution 
is  advisable. 

The  patient's  general  health  should  be  looked  after.  Rest 
in  bed  is  frequently  beneficial.  When  depression  exists,  opium 
frequently  gives  relief,  and  during  the  periods  of  excitement 
the  administration  of  hyoscin,  together  with  rest  in  bed  and  the 
application  of  warm  packs  tend  to  alleviate  the  condition. 
Restlessness  and  insomnia  can  frequently  be  relieved  by  the  ad- 
ministration of  bromids.  In  the  later  stages  of  the  disease  care 
should  be  taken  in  feeding  of  the  patient  so  as  to  prevent  par- 
ticles of  food  from  entering  the  lungs.  The  development  of 
bed-sores  should  be  prevented  if  possible,  and  the  bow^els  and 
bladder  should  receive  careful  attention. 

Naturally,  in  each  case  of  paresis  the  question  arises  whether 
or  not  the  condition  is  amenable  to  antisyphilitic  treatment. 
In  my  opinion  every  paralytic  should  receive  a  thorough  course 
of  treatment  and  the  effects  thereof  be  noted.  This,  of  course, 
applies  only  to  those  cases  in  which  the  diagnosis  is  made  in  the 
first  or  second  stage  of  the  disease,  and  whose  general  condition 
warrants  the  administration  of  vigorous  antis}^hilitic  treat- 
ment. Salvarsan  should  be  given  intravenously  in  appropriate 
doses  at  intervals  of  two  or  three  weeks.  Simultaneously  with 
the  salvarsan  should  be  given  intraspinous  and  intraventricular 
injections  of  salvarsanized  serum  containing  a  small  dose  of  mer- 
curic chlorid.  In  the  intervals  between  the  administration  of 
salvarsan,  and  beginning  three  days  after  the  injection  and  stop- 
ping two  days  before  an  injection,  mercurial  inunctions  should 
be  made  daily,  and  potassium  iodid  in  moderately  large  doses 
should  be  administered  internally.  The  effect  of  this  treat- 
ment upon  the  blood  and  spinal  fluid  should  be  noted  by 
proper  serologic  and  chemical  examinations.  It  is  the  expe- 
rience of  those  who  have  used  this  form  of  treatment  that  some 
few  patients  are  improved,  that  the  general  condition  of  most 
cases  is  rendered  better,  and  that  a  few  have  been  cured. 


DISEASES   OF  THE   BRAIN   AND  SPINAL 

CORD 

SYPHILIS   OF  THE   NERVOUS   SYSTEM 

About  io  per  cent,  of  all  persons  who  become  infected  with 
syphilis  show  involvement  of  the  nervous  system  at  a  later 
date.  The  nervous  system,  it  would  seem,  is  more  apt  to  be 
involved  in  those  cases  that  showed  the  mildest  symptoms  at 
the  onset.  Thorough  treatment  in  the  first  and  second  stages 
has  not  always  prevented  involvement  of  the  nervous  system 
at  a  subsequent  period.  At  the  present  time,  as  the  result  of 
more  recent  methods  of  treatment,  this  sequel,  it  is  hoped, 
may  be  avoided. 

When  syphilis  involves  the  nervous  system,  it  does  so  in  one 
of  several  w^ays:  First,  the  meninges,  superficial  tissues,  and 
perivascular  spaces  may  be  invaded  by  gummy  exudative 
material:  this  is  particularly  apt  to  occur  within  a  few  months 
after  infection.  Second,  there  may  be  cellular  infiltration  of 
the  membranes,  brain,  spinal  cord,  or  nerves,  which  is  of  a  more 
or  less  chronic  nature.  Third,  the  nervous  system  may  be  so 
affected  as  to  give  rise  to  conditions  that  were  formerly  called 
parasyphilitic,  but  which  we  now  believe  to  be  due  directly  to 
the  presence  of  the  Spirochseta  pallida  or  its  products.  Fourth, 
the  blood-vessels  of  the  central  nervous  system  may  be  affected 
as  the  result  of  the  activity  of  the  Spirochaeta  pallida,  or  of  sub- 
stances formed  during  the  life  of  this  organism,  bringing  about 
either  an  endarteritis,  with  consequent  decrease  in  the  lumen 
of  the  vessel,  or  degenerative  changes  of  the  vessel- walls  which 
may  either  interfere  with  the  proper  cerebrospinal  circulation, 
or,  by  weakening  their  walls,  predispose  them  to  rupture. 
Fifth,  in  many  cases  there  is  a  combination  of  two  or  more  of 
the  preceding  conditions. 

The  symptoms  of  s>^hilitic  affection  of  the  nervous  system 
may  be  conveniently  grouped  as  follows:  First,  those  symptoms 

459 


460  MANUAL  OF  NERVOUS  DISEASES 

that  are  caused  by  syphilitic  disease  of  some  structure  adjacent 
to  the  nervous  system,  which,  by  extension,  interferes  with  or 
affects  the  functions  of  the  nervous  organism;  such  are  severe 
head  pain,  caused  by  a  syphihtic  periostitis;  pressure  on  nerves 
or  the  spinal  cord,  caused  by  syphilitic  disease  of  the  surround- 
ing structures,  etc.  The  cause  of  these  symptoms  can  usually 
be  discovered  as  the  result  of  proper  physical  and  laboratory 
examinations. 

A  second  group  of  cases,  in  which  the  manifestations  are  due 
to  syphilitic  exudation  about  the  blood-vessels,  in  the  meninges 
of  the  brain,  and  in  the  spinal  cord,  are  usually  observed  soon 
after  the  initial  infection.  This  exudate  occurs  as  a  diffuse, 
transparent,  sticky  mass,  or  it  may  be  localized,  forming  a 
tumor.  Such  tumors  are  often  multiple.  This  exudate  is 
usually  deposited  rapidly,  and  produces  pressure  upon  both 
the  neural  and  the  vascular  tissue  in  its  immediate  neighbor- 
hood, causing  suspension  of  function  of  these  tissues.  The 
symptoms  that  arise  as  the  result  of  the  presence  of  this  sub- 
stance depend  upon  its  location.  There  are  generally  head- 
ache, which  is  worse  at  night,  restlessness,  and  general  discom- 
fort. To  these  there  are  added  more  or  less  suddenly  dis- 
turbance of  the  functions  of  the  brain,  such  as  epileptiform  at- 
tacks, disorders  of  consciousness,  the  various  cranial  nerve 
palsies,  optic  neuritis,  partial  or  complete  hemiplegia  or  hemi- 
anesthesia, etc.  In  other  cases  there  may  be  a  gradually  in- 
creasing headache,  accompanied  by  increasing  mental  dul- 
ness,  to  which  may  be  added  disturbance  of  the  pupillary  reac- 
tion, optic  neuritis,  etc.  Other  cases  are  seen  that  present  only 
the  symptoms  of  tumor  of  brain.  In  those  cases  in  which  the 
blood-vessels  are  principally  involved  the  symptoms  that  arise 
are  those  referable  to  interference  with  the  cerebral  circula- 
tion. 

In  those  cases  in  which  the  exudate  involves  the  spinal  cord, 
there  will  be  pain  in  the  back,  disturbances  of  sensibility  on 
the  trunk  and  lower  extremities,  and  perhaps  sharp  shooting 
pains  and  girdle  sensation,  disorders  in  the  control  of  the 
bowels  and  bladder,  together  with  more  or  less  weakness  of 
the  extremities,  depending  upon  the  location  of  the  lesion. 


SYPHILIS    OF   THE   NERVOUS    SYSTEM  46 1 

The  more  extensive  the  involvement  of  the  meninges,  the  more 
severe  will  be  the  pain  and  rigidity;  and  the  more  marked  the 
involvement  of  the  cord  substance  itself,  the  more  prominent 
will  be  the  symptoms  that  can  be  referred  to  the  interference 
with  the  transmission  of  impulses  upward  and  downward 
through  the  cord. 

In  those  cases  in  which  there  is  a  cellular  infiltration  into 
the  membranes  or  nervous  tissue  itself,  the  symptoms  are 
usually  of  slow  onset,  the  condition  running  a  chronic  course. 
If  this  infiltrative  process  chiefly  involves  the  membranes,  the 
most  prominent  symptoms  are  those  of  a  chronic  meningitis; 
if,  on  the  other  hand,  the  nervous  tissues  are  principally  in- 
volved, symptoms  appear  that  may  resemble  general  paresis, 
multiple  sclerosis,  diffuse  myelitis,  and  bulbar  paralysis. 

The  so-called  parasyphilitic  diseases — tabes  dorsalis  and 
general  paresis — are  described  in  other  sections  of  this  volume. 

The  symptoms  that  occur  as  the  result  of  syphilitic  disease 
of  the  blood-vessels  of  the  brain  and  spinal  cord  differ  in  no 
way  from  those  symptoms  that  have  been  described  in  previous 
chapters,  dealing  with  vascular  diseases  of  the  brain  and  cord. 

Hereditary  syphilitic  diseases  of  the  nervous  system  usually 
appear  during  the  first  period  of  life,  but  frequently  may  not  be- 
come evident  until  puberty.  The  pathologic  changes  are 
practically  identical  with  those  that  occur  in  acquired  syphilis. 
In  hereditary  syphilis  the  symptoms  are  prone  to  be  more  severe 
and  extensive  than  in  acquired  syphilis,  and  inhibitions  in  the 
development  of  the  neural  tissue  are  frequent. 

The  diagnosis  of  syphilis  of  the  nervous  system  is  usually 
readily  made ;  in  doubtful  cases  a  Wassermann  test  of  the  blood 
and  spinal  fluid,  the  Noguchi  and  other  tests  of  the  spinal  fluid, 
and  the  cell  count  of  the  spinal  fluid  will  generally  enable  one  to 
reach  a  correct  conclusion. 

Prognosis. — Under  proper  treatment  the  prognosis  as  regards 
cure  of  the  syphilitic  process  is  very  good:  those  cases  in  which 
the  symptoms  are  due  to  exudative  syphilitic  processes  almost 
always  clear  up;  those  in  which  the  symptoms  are  due  to  an 
infiltrative  process  usually  improve,  but  some  permanent  symp- 
toms may  remain.    The  parasyphilitic  affections  can  now  be 


462  MANUAL   OF   NERVOUS   DISEASES 

greatly  improved,  and  the  course  of  the  process  in  many  cases 
arrested.  Those  symptoms  that  arise  as  the  result  of  destruc- 
tion or  degeneration  of  a  portion  of  the  nervous  tissue  remain 
permanently.  Cases  that  are  due  to  syphilitic  affection  of  the 
blood-vessels  may  or  may  not  be  relieved  by  treatment,  de- 
pending altogether  upon  the  character  of  the  vascular  involve- 
ment. Patients  in  whom  the  perivascular  tissues  are  affected 
may  be  greatly  benefited  by  treatment.  In  those  cases  in  which 
the  intima  is  involved,  with  the  production  of  an  endarteritis, 
the  process  may  be  arrested  and  the  symptom's  alleviated,  but 
not  entirely  eliminated.  Symptoms  due  to  hereditary  syph- 
ilis offer  the  same  prognosis  as  to  recovery  under  treatment  as 
do  those  due  to  acquired  syphilis,  with  the  exception  of  those 
manifestations  that  are  due  to  arrest  of  development  of  the 
nervous  tissue. 

Prophylaxis  of  Syphilis  of  the  Nervous  System. — This  end  is 
best  subserved  by  beginning  the  thorough  treatment  of  syph- 
ilis as  soon  as  the  diagnosis  is  made.  In  addition  to  the  usual 
methods  of  treatment,  which  will  be  described  further  on,  in 
every  case  of  syphilitic  infection,  at  some  time  during  the  course 
of  treatment,  and  certainly  before  the  patient  is  discharged  as 
cured,  spinal  puncture  should  be  made  and  the  spinal  fluid 
carefully  examined.  If  there  is  evidence  of  involvement  of  the 
nervous  system,  even  in  the  presence  of  negative  findings  in 
the  blood,  the  proper  treatment,  described  below,  should  be 
administered. 

Treatment. — The  treatment  of  syphilis  of  the  nervous  sys- 
tem has  as  its  basis  the  complete  eradication  of  the  syphilitic 
virus  from  the  blood,  the  various  organs  and  parts  of  the  body, 
and  the  central  nervous  system.  There  are  certain  peculiari- 
ties of  the  nervous  system  that  must  be  taken  into  considera- 
tion when  treatment  is  directed  toward  the  cure  of  syphilitic 
diseases  of  this  portion  of  the  body:  the  first  is  the  difficulty 
with  which  medicinal  substances  can  be  made  to  penetrate  the 
deeper  portions  of  the  brain  and  spinal  cord;  second,  the  pecu- 
liar fact  that  the  choroidal  plexus  practically  does  not  allow 
the  passage  of  metallic  substances  from  the  blood  into  the 
cerebrospinal  fluid. 


SYPHILIS    OF    THE    NERVOUS    SYSTEM  463 

At  the  present  time,  from  the  large  number  of  drugs  at  our 
disposal,  mercury  and  arsenic  seem  to  stand  out  preeminently 
as  the  two  substances  on  which  we  must  rely  in  order  to  hope 
to  effect  a  cure  of  sv'philis.  The  iodids,  although  very  useful, 
and  I  might  say  almost  indispensable,  for  the  relief  of  symptoms, 
certainly  cannot  be  classed  among  the  drugs  to  be  employed  for 
the  eradication  of  the  Spirochaeta  pallida.  Mercury  can  be  in- 
troduced into  the  system  by  w^ay  of  the  mouth,  by  inhalation, 
injection,  and  inunction,  and  at  times  it  may  be  necessar}"  to 
employ  several  of  these  routes.  As  a  rule,  however,  the  best 
results,  with  the  fewest  disagreeable  manifestations,  are  ob- 
tained by  means  of  inunctions.  Salvarsan,  of  course,  is  now 
almost  universally  given  by  the  intravenous  method. 

It  has  been  my  experience  that  s>philitic  disease  of  the 
nervous  system  yields  most  promptly  to  the  followdng  line  of 
treatment,  which  should  alw^ays  be  controlled  by  the  Wasser- 
mann  examination  of  the  blood  and  spinal  fluid,  including  the 
cell  count  and  the  globulin  reaction  of  the  spinal  fluid.  The 
patient  is  given  a  dose  of  salvarsan  appropriate  to  his  age,  and 
two  days  later  I  advise  the  use  of  mercurial  inimctions  daily. 
This  treatment  is  continued  for  thirty  days,  unless  contraindi- 
cations arise,  when  salvarsan  is  again  given,  followed  by  the 
mercurial  inunctions.  This  proceedure  is  continued  until  the 
symptoms  have  disappeared  and  the  Wassermann  examination 
of  the  blood  is  negative.  Examinations  should  be  made  once 
every  six  months  for  several  years.  In  those  cases  that  show  a 
positive  Wassermann,  increased  cell-count,  and  globulin  in  the 
cerebrospinal  fluid  the  treatment  consists  of  inunctions  of 
mercury,  the  intravenous  injection  of  salvarsan,  and  the  intra- 
spinous  and  at  times  the  intraventricular  administration  of 
autosalvarsanized  and  mercurialized  serimi. 

The  following  is  an  outline  for  the  treatment  of  a  patient 
affected  with  s>nphilis  of  the  ner\^ous  system  who  has  positive 
findings  in  both  blood  and  cerebrospinal  fluid:  If  the  patient  is 
an  adult,  he  is  given  sLx-tenths  of  a  gram  of  salvarsan  intra- 
venously; then,  following  the  technic  of  Swift  and  Ellis,  a  60  per 
cent,  autosalvarsanized  serum  is, prepared;  to  about  30  c.c. 
of  this  solution  I  usually  add  one-fiftieth  of  a  grain  of  mercuric 


464  MANUAL   OF  NERVOUS   DISEASES 

chlorid.  A  spinal  puncture  or  ventricular  puncture  is  made,  a 
proper  amount  of  cerebrospinal  fluid  is  withdrawn,  and  the 
autosalvarsanized  and  mercurialized  serum  is  slowly  injected 
into  the  subdural  space  or  into  the  ventricle.  Following 
this  procedure  there  may  be  some  reaction,  consisting  of 
general  malaise,  headache,  vomiting,  diarrhea,  pain  in  the 
back,  pain  in  the  legs,  and  sometimes  bowel  and  bladder  dis- 
turbance. This  reaction  may  last  for  one  or  two  days,  and  vary 
in  severity.  On  the  third  day  after  this  treatment  the  patient 
should  receive  an  inunction  of  one  dram  or  more  of  mercurial 
ointment,  repeated  daily,  care  being  taken  to  avoid  salivation. 
Potassium  iodid  in  suitable  doses  is  also  administered.  After 
three  or  four  weeks  the  mercury  and  iodid  are  discontinued  for 
two  days,  and  an  examination  of  the  blood  and  spinalr  fluid 
made.  If  these  are  still  positive,  the  same  course  of  treatment 
is  repeated,  and  continued  until  both  blood  and  spinal  fluid 
become  negative.  After  this  a  Wassermann  test  of  blood  and 
spinal  fluid  should  be  made  at  intervals  of  six  months  for  two 
years.  In  those  cases  in  which  the  spinal  fluid  becomes  nega- 
tive before  the  blood,  the  intraspinous  injections  may  be  dis- 
continued, but  the  salvarsan,  mercurial  inunctions,  and  potas- 
sium iodid  should  be  continued.  As  long  as  the  spinal  fluid 
shows  positive  findings  it  is  necessary  to  continue  the  treatment 
as  directed,  giving  salvarsan  intravenously,  salvarsanized  mer- 
curialized serum  intraspinally  or  intraventricularly,  and  inunc- 
tions daily  in  the  intervals  between  the  administration  pf  the 
salvarsan  and  the  giving  of  the  potassium  iodid  if  symptoms 
are  present. 

If,  after  the  treatment,  there  is  no  reappearance  of  pathologic 
findings  in  the  blood  or  cerebrospinal  fluid,  we  may  safely  con- 
clude that  a  method  has  been  used  that  promises  a  complete 
cure  of  the  syphilitic  infection.  It  is,  of  course,  too  much  to 
expect  that  any  form  of  treatment  will  restore  the  original 
function  of  those  structures  that  have  been  destroyed  as  the 
result  of  the  disease :  the  most  we  can  expect  is  that  the  method 
of  treatment  will  permanently  eradicate  the  cause  of  the  dis- 
ease. 


MULTIPLE   SCLEROSIS    (DISSEMINATED    SCLEROSIS)      465 

MULTIPLE  SCLEROSIS  (DISSEMINATED  SCLEROSIS) 

Multiple  sclerosis  is  a  disease  that  begins  in  youth.  It  is 
characterized  by  the  production,  in  the  central  nerv^ous  system, 
of  small  areas  of  sclerotic  tissue  that  are  irregular  in  distribu- 
tion. 

Etiology. — This  disease  usually  manifests  itself  between  the 
tenth  and  the  twenty-fifth  year,  although  no  age  is  exempt. 
Soine  cases  occur  early  in  childhood,  and  others  do  not  mani- 
fest themselves  until  later  in  life.  Cold,  injury,  infectious  dis- 
eases, and  toxic  agents  are  all  believed  to  predispose  to,  or  act 
as  exciting  factors  of,  the  disease.  It  is  now  generally  believed 
that  this  disease  is  a  sequel  of  one  of  the  acute  infectious  diseases, 
such  as  typhoid,  influenza,  whooping-cough,  acute  articular 
rheumatism,  scarlet  fever,  etc.  It  has  also  been  observed  to 
follow  chronic  intoxication  with  metallic  poison.  The  disease 
has  no  connection  with  s}^hilis.  By  some  observers,  a  con- 
genital maldevelopment  of  the  nervous  system  is  regarded  as 
the  direct  cause,  while  the  infectious  diseases,  trauma,  toxemia, 
etc.,  are  considered  to  be  the  exciting  causes.  In  many  cases 
no  cause  is  discoverable. 

Pathology. — Macroscopically,  there  can  be  seen  scattered 
over  the  surface  of  the  brain,  medulla,  and  spinal  cord  areas  of 
varying  sizes  and  shapes  and  grayish-blue  in  color.  These  are 
especially  prominent  on  transverse  section.  They  var\"  in  size: 
some  are  so  large  as  to  permeate  almost  the  whole  thickness  of 
the  cord  or  medulla,  or  they  may  be  so  small  as  to  be  recognized 
only  microscopically.  These  areas  may  principally  involve 
the  cord,  medulla,  or  brain,  or  all  three  of  these  structures  may 
be  involved  more  or  less  equally.  They  also  occur  frequently 
in  the  optic  tracts  and  chiasm.  These  foci  are  usually  sharply 
defined,  and  may  assume  any  form.  They  are  generally  of 
a  firmer  consistency  than  the  normal  nerv^e  tissue,  and  frequently 
there  is  some  infiltration  of  the  tissue  outside  of  the  focus. 

Histologic  examination  of  the  foci  shows  disintegration  of  the 

myelin  sheaths  of  the  fibers,  with  persistence  of  the  axis-cylinder 

process  and  an  increase  of  the  interstitial  tissue.    The  foci  in 

the  gray  matter  afiect  the  cells  to  a  very  slight  extent.    Fre- 

30 


•466  MANUAL   OF   NERVOUS   DISEASES 

quently  there  occur  the  formation  of  new  blood-vessels  and  oc- 
clusion of  others.  Owing  to  the  fact  that  the  axis-cylinder 
process  and  the  cells  are  spared  in  these  sclerotic  patches,  there 
is  almost  a  complete  absence  of  secondary  degeneration.  It 
would  seem  as  though  a  toxic  substance,  exercising  a  selective 
activity  on  the  myelin  sheaths,  caused  their  destruction,  to- 
gether with  a  proliferation  of  the  neurogliar  elements,  and 
spared  the  cells  and  the  axis-cylinder  processes.  No  explana- 
tion can  be  given  for  the  peculiar  and  irregular  distribution  of 
the  foci. 

Symptoms. — ^There  are  three  symptoms  that  occur  in  practi- 
cally all  cases.  They  are  intention  tremor,  nystagmus,  and 
disturbance  of  speech.  When  one  takes  into  consideration  the 
fact  that  the  early  symptoms  of  this  disease  may  be  due  to  in- 
volvement of  the  spinal  cord,  the  brain-stem,  or  some  other 
portion  of  the  nervous  system,  and  that  in  some  cases  there  is 
complete  intermission  of  or  disappearance  of  certain  symptoms 
for  many  months,  with  their  reappearance  at  some  later  date,  it 
can  be  seen  how  difficult  it  is  to  describe  accurately  the  early 
stages  of  this  disease.  The  symptoms  are  usually  very  gradual  in 
their  development:  the  patient  may  complain  of  numbness  and 
weakness  in  the  legs,  which  slowly  increase  until  the  gait  be- 
comes spastic,  ataxic,  or  of  the  cerebellar  type.  In  some  cases 
little  or  no  weakness  develops,  but  the  legs  become  extremely 
stiff,  with  increased  knee-jerks,  ankle-clonus,  and  the  Babinski 
sign.  Decrease  or  absence  of  the  superficial  reflexes  often  occurs 
early.  Usually,  when  the  patient  walks  the  entire  body  sways. 
In  some  cases,  along  with  the  spastic  impairment  of  gait  there 
is  also  marked  uncertainty,  so  that  there  is  danger  of  falling. 
Active  movements  of  the  limbs,  head,  or  trunk  are  usually  ac- 
companied by  tremor. 

Tremor  is  absent  during  rest,  but  when  the  patient  attempts  to 
perform  some  voluntary  act,  from  the  beginning  of  the  attempt 
until  its  completion  a  tremor  appears  that  involves  the  entire 
limb,  and  increases  in  amplitude  as  the  act  nears  its  completion. 
This  is  called  an  intention  tremor,  and  is  so  definitely  character- 
istic of  the  disease  as  to  be  almost  pathognomonic.  Early  in 
the  disease  the  tremor  may  not  be  associated  with  weakness; 


MULTIPLE    SCLEROSIS    (DISSEMINATED    SCLEROSIS)      467 

later,  however,  weakness  and  rigidity  occur,  which  are  generally 
more  marked  in  the  legs  than  in  the  arms. 

On  lateral  or  upward  movements  of  the  eyeballs  nystagmus 
appears  early;  later  in  the  disease  it  may  be  constantly  present. 
The  pupils  are  often  unequal,  but  always  respond  to  light. 
Occasionally  weakness  or  paralysis  of  one  or  more  of  the  ocular 
muscles  occurs.  In  many  cases  the  optic  nerve  becomes  affected, 
and  frequently  this  affection  of  the  optic  nerve  is  an  early  sign 
of  the  disease.  There  is  usually  pallor  of  the  optic  disc,  and 
atrophy  limited  to  a  portion  of  the  optic  nerv^e  is  very  common. 
The  visual  disturbances  in  this  disease  may  vary  from  day  to 
day,  and  at  times  may  even  disappear. 

The  speech  is  frequently  disturbed:  it  becomes  very  slow,  the 
words  being  pronounced  syllable  by  syllable,  with  pauses  between ; 
this  condition  is  known  as  "scanning  speech,"  and  may  be 
preceded  for  a  considerable  time  by  mere  slowing  of  the  speech. 
Apoplectiform  and  epileptiform  seizures  are  uncommon.  At- 
tacks of  uncontrollable  laughter,  of  depression,  of  emotional 
disturbances,  etc.,  occur  w^ithout  cause  early  in  the  disease. 
Affections  of  sensibility  are  rarely  absent  throughout  the  disease, 
but  are  seldom  permanent  or  severe.  The  patient  frequently 
complains  of  paresthesia  and  pains  in  the  extremities,  trunk, 
and  head;  these  usually  come  on  in  attacks,  and  may  be  very 
severe.  Disturbances  of  the  rectal  and  vesical  reflexes  may  occur, 
but  complete  or  permanent  paralysis  is  exceptional.  In  some 
eases  there  is  a  disturbance  of  the  mtellectual  functions,  a  lack 
of  interest  develops,  together  with  forge tfulness  and  confusion, 
but  marked  mental  disturbances  are  rare. 

When  the  spinal  cord  is  first  and  principally  affected,  a 
spastic  weakness  in  the  lower  extremities  usually  develops, 
which  may  or  may  not  be  accompanied  by  atrophy  of  the  muscles, 
bowel  and  bladder  disturbances,  etc.  In  these  cases  bulbar 
and  cerebral  symptoms,  by  later  development,  reveal  the  true 
disease.  In  other  cases  bulbar  symptoms  are  the  first  to  appear, 
whereas  in  still  others  the  cerebral  symptoms  may  be  the  first 
evidence  of  the  disease. 

Diagnosis. — Multiple  sclerosis  is  differentiated  from  hysteria 
by  the  fact  that  nystagmus,  optic  atrophy,  the  loss  of  control- 


468  MANUAL   or   NERVOUS   DISEASES 

of  the  sphincters,  and  the  pecuHar  movements  of  the  body  and 
head  do  not  occur  in  hysteria.  A  study  of  the  case  generally 
enables  one  to  make  the  differentiation,  but  there  are  some  cases 
in  which  there  is  an  absence  of  objective  symptoms  which  renders 
the  diagnosis  extremely  difficult.  From  lateral  sclerosis  this 
disease  is  differentiated  by  the  appearance  of  cerebral  symptoms, 
such  as  scanning  speech,  nystagmus,  and  emotional  disturbances, 
and  by  the  occurrence  of  remissions,  which  are  absent  in  lateral 
sclerosis.  From  locomotor  ataxia  it  is  differentiated  by  the 
presence  of  speech  disturbance,  nystagmus,  and  intention 
tremor.  If  multiple  sclerosis  begins  with  cerebral  symptoms, 
it  may  be  mistaken  for  cerebral  tumor,  vascular  disturbances, 
or  encephalitis.  From  tumor  of  the  brain  it  is  distinguished  by 
the  absence  of  symptoms  of  increased  intracranial  pressure 
and  by  the  frequent  presence  of  choked  disc  in  tumors.  More- 
over, in  tumors  the  symptoms  usually  increase  gradually, 
whereas  in  multiple  sclerosis  there  may  be  remissions  and 
exacerbations.  From  vascular  disturbances  the  differentiation 
cannot  always  be  made  if  multiple  sclerosis  begins  with  an  apo- 
plectiform seizure,  and  only  the  further  course  of  the  disease  will 
definitely  determine  the  diagnosis.  From  cerebrospinal  syphilis 
multiple  sclerosis  is  differentiated  by  examination  of  the  blood 
and  spinal  fluid. 

Course  and  Prognosis. — The  disease  almost  always  runs  a 
chronic  course,  with  frequent  remissions  and  sometimes  even 
intermissions.  In  many  cases  there  are  repeated  intermissions 
that  may  even  simulate  recovery;  these  intermissions  may  last 
for  months,  for  a  year,  or  even  longer,  and  be  followed  by  a 
reappearance  of  the  symptoms,  which  increase  in  number  and 
in  severity,  until,  after  a  number  of  attacks,  they  become  per- 
manent and  the  disease  progresses.  The  recurrences  may  be 
spontaneous,  or  they  may  be  brought  about  by  some  harmful 
condition,  such  as  exposure,  overexertion,  or  following  infection. 
The  prognosis  as  to  recovery  is  unfavorable,  although  some  cures 
have  been  reported.  The  earlier  this  disease  develops  in  life, 
the  better  would  seem  to  be  the  chance  of  arrest.  The  appear- 
ance of  bulbar  symptoms  should  always  give  rise  to  apprehen- 
sion, as  there  is  great  danger  to  life  from  respiratory  involve- 


CAISSON   DISEASE  469 

ment  and  from  disturbance  of  nutrition  secondary  to  inter- 
ference with  deglutition. 

Treatment. — There  is  no  specific  remedy  for  this  disease. 
]\Iild  hydrotherapy,  gentle  massage,  and  proper  attention  to 
nutrition  and  to  elimination  are  all  of  service  in  staying  the 
progress  of  the  disease.  Rest,  both  mental  and  physical,  all 
movements  being  absolutely  avoided,  seems  to  be  of  the  greatest 
assistance  in  arresting  the  progress  of  the  disease. 

CAISSON   DISEASE 

Etiology. — This  is  a  condition  which  affects  those  individuals 
who  work  under  increased  atmospheric  pressure,  such  as  bridge- 
builders,  divers,  miners,  etc.,  who,  after  being  subjected  to  a 
pressure  of  from  two  to  six  atmospheres  for  some  time,  suddenly, 
without  taking  proper  precautions,  emerge  from  the  high  at- 
mospheric pressure  into  one  much  lower. 

Healthy  men  are  much  less  likely  to  be  affected  by  this  disease 
than  are  those  who  overindulge  in  alcoholic  drinks  or  who  have 
heart  or  kidney  diseases. 

Pathology. — ^As  a  result  of  sudden  decrease  of  atmospheric 
pressure,  gas-bubbles  escape  from  the  blood,  causing  air  emboli 
in  the  small  vessels.  In  those  cases  that  do  not  recover  secondary 
softening  of  the  cord  or  brain  takes  place.  The  extent  of  the 
softening  depends  upon  the  size  of  the  vessel  that  is  occluded. 
Fortunately ,  in  the  majority  of  cases  the  emboli  are  of  microscopic 
size  and  are  located  in  the  capillaries,  hence  the  areas  of  in- 
farction are  minute,  and  the  collateral  circulation  is  suf&cient 
to  bring  about  rapid  restoration  of  the  nutrition  and  function 
of  the  affected  area.  In  those  cases  in  which  the  larger  vessels 
are  occluded,  softening  of  the  cord  or  brain  follows,  which 
causes  either  chronic  symptoms  or  death.  In  those  cases  that 
survive  for  a  few^  days,  air  emboli  are  not  found,  but  the  areas  of 
softening,  with  their  degenerative  changes,  are  seen. 

Symptoms. — The  symptoms  develop  within  a  ver\^  short 
time  after  the  individual  emerges  suddenly  from  under  increased 
atmospheric  pressure  to  one  much  lower.  The  symptoms  are 
both  cerebral  and  spinal:  there  is  a  feeling  of  pressure  on  the 


47^  MANUAL  OF  NERVOUS  DISEASES 

head,  vertigo,  tinnitus,  vomiting,  cramp-like  pain  in  the  back 
and  legs,  weakness  or  paralysis,  and  occasionally  respiratory 
and  cardiac  disturbances.  Some  patients  lose  consciousness. 
In  some  cases  the  symptoms  point  almost  entirely  to  involve- 
ment of  the  spinal  cord:  there  occur  pain  in  the  back  and  legs, 
weakness  or  paralysis  of  the  legs,  sensory  disturbances,  and  loss 
of  bowel  and  bladder  control.  All  these  symptoms  usually 
develop  within  a  few  hours.  In  some  cases  the  symptoms 
subside  almost  as  rapidly  as  they  develop,  and  in  a  short  time 
the  patient  has  entirely  recovered;  in  other  cases  the  spinal  or 
cerebral  symptoms  persist,  and  the  symptoms  either  of  myelo- 
malacia or  of  cerebral  softening  develop. 

Prognosis. — The  prognosis  is  fairly  good,  except  in  alcoholics, 
and  in  those  suffering  from  heart  and  kidney  disease;  even  in 
these  the  prognosis  is  not  necessarily  bad  if  the  condition  is  rec- 
ognized and  the  individual  returns  rapidly  to  a  chamber  in 
which  the  atmospheric  pressure  can  be  increased. 

Treatment. — It  is  most  important  to  warn  individuals  against 
rapid  changes  from  high  to  low  pressure — the  changes  should  be 
made  very  gradually.  When  the  symptoms  develop,  the 
patient  should  be  immediately  placed  under  increased  atmos- 
pheric pressure,  either  by  returning  him  to  the  place  from  which 
he  came,  or  by  placing  him  in  a  pneumatic  cabinet,  where  a 
high  atmospheric  pressure  can  be  quickly  produced,  and  then 
gradually  returning  him  to  the  lower  atmospheric  pressure. 
Ergot  in  large  doses  every  two  hours  and  bandging  of  the  limbs 
have  been  recommended,  in  order  to  confine  the  blood  to  the 
body  cavities.  After  the  acute  stage  of  the  attack  has  passed, 
the  treatment  is  that  usually  given  for  spinal  or  cerebral  soften- 
ing. 


DISEASES     OF    THE    NERVOUS     SYSTEM 
WITHOUT   PATHOLOGIC   FINDINGS 

HYSTERIA 

Hysteria  is  a  condition  characterized  by  the  presence  of  an 
abnormal  mental  condition  that  manifests  itself  by  an  increased 
suggestibility,  great  emotional  mobility,  and  the  occurrence  of 
symptoms  of  varying  degrees  of  severity,  involving  the  emotions, 
the  motor,  the  sensory,  and  the  vasomotor  system,  and  fre- 
quently the  occurrence  of  abnormal  states  of  consciousness 
and  of  the  mind. 

Etiology. — This  disease  manifests  itself  for  the  first  time 
most  frequently  between  the  age  of  puberty  and  the  thirtieth 
year.  It  may  occur  earlier  in  life,  being  very  uncommon  be- 
before  the  tenth  year,  although  it  may  occur  in  very  marked 
form  in  the  earliest  years  of  life.  After  the  twenty-fifth  year 
there  is  a  decrease  in  the  frequency  with  which  the  disease  mani- 
fests itself  for  the  first  time.  Women  are  affected  somewhat 
more  frequently  than  men.  The  disease  is  more  common  in 
the  Latin,  Hebrew,  and  the  Slavonic  races  than  in  the  Anglo- 
Saxon  and  the  Teuton. 

Heredity  is  a  most  important  predisposing  factor.  Fre- 
quently there  is  a  history  of  hysteria  in  the  mother  or  father, 
and  in  other  cases  neuropathic  taints,  exhausting  disease, 
alcoholism,  etc.,  are  discovered  in  the  ancestry.  Prolonged 
illness,  over^^ork,  worry,  changes  in  one's  surroundings,  occupa- 
tions that  involve  intense  mental  strain  or  anxiety,  etc.,  may 
also  act  as  predisposing  causes.  Among  the  exciting  causes 
are  fright,  shock,  worry,  unhappiness,  disappointment,  fear, 
incompetence,  inability  to  attain  one's  desires,  imitation,  home- 
sickness, the  adminstration  of  anesthetics,  acute  infectious 
diseases,  toxemia,  etc.,  or  any  combination  of  these  causes  may 
act  as  the  direct  excitant  of  a  hysteric  condition. 

471 


472  MANUAL   OF   NERVOUS   DISEASES 

Theoretic  Etiology  of  Hysteria. — Practically  all  authorities 
agree  that  in  hysteria  there  is  an  underlying  abnormal  mental 
state  that  is  of  congenital  origin,  and  that  this  mental  condition 
is  characterized  by  a  more  or  less  marked  emotional  mobility 
and  susceptibility  to  suggestion.  These  individuals  are  usually 
rather  superficial  in  their  judgment,  lack  self-control,  and  are 
more  or  less  egotistic  and  inconsistent  in  character.  There  is 
an  exaggerated  susceptibility  to  external  or  internal  impressions, 
and,  in  addition,  hysteric  individuals  are  usually  fearful,  evasive, 
and  unwilling  to  meet  the  disappointments  of  life  in  a  frank 
manner.  The  hysteric  tendency  may  remain  latent  and  never 
become  manifest.  In  many  instances,  however,  as  the  result 
of  disagreeable  or  unfortunate  experiences  occurring  in  early 
life,  before  puberty,  during  adolescence,  and  sometimes  later, 
there  is  produced  a  form  of  mental  distress  which  the  indi- 
vidual is  unwilling  to  face  openly,  and  consequently  the  thoughts 
or  the  occurrences  that  give  origin  to  this  discomfort  are  re- 
pressed and  disappear  from  consciousness.  These  repressed 
ideas  still  remain  active,  and  become  converted  into  some  form 
of  physical  or  mental  reaction,  which  may  evidence  itself 
symptomatically  in  the  shape  of  motor,  sensory,  vasomotor,  or 
mental  phenomena. 

Many  persons  possessing  a  hysteric  temperament  show 
symptoms  that  are  defensive  reactions;  such  individuals,  as  the 
result  of  incompetence,  unhappiness,  a  desire  for  attention, 
unwillingness  to  face  their  failures,  disappointments,  or  neglect, 
unconsciously  endeavor  to  cover  over  these  deficiencies  by  symp- 
toms of  illness.  In  some  cases,  as  the  result  of  prolonged  illness, 
overwork,  insufficient  food,  worry,  or  toxic  conditions,  there 
occurs  a  more  or  less  marked  decrease  in  the  normal  powers  of 
inhibition.  In  these  individuals,  in  the  presence  of  some  acute, 
exciting  cause,  attacks  occur  that  are  characterized  by  symptoms 
of  lack  of  self-control,  such  as  immoderate  weeping,  laughing, 
trembling,  restlessness,  etc.  It  will  also  be  observed  that  in 
these  patients  the  emotions  exert  an  abnormal  influence  upon 
the  motor,  sensory,  and  secretory  functions.  As  a  result  of 
the  exaggerated  suggestibility,  the  expected  or  preconceived 
ideas  are  followed  by  exaggerated  reactions  of  a  negative  or 


HYSTERIA  473 

positive  kind,  which  may  be  of  motor,  sensory,  vasomotor,  or 
psychic  character.  For  example,  as  the  result  of  a  fright,  with 
or  without  actual  injury,  the  individual  may  develop  a  paralysis 
or  contracture,  anesthesia,  or  great  pain,  etc. 

Symptoms. — This  disease  is  characterized  by  a  more  or  less 
well-marked  mental  peculiarity.  While  this  peculiarity  is 
usuallv  present,  in  some  individuals  it  may  remain  latent  and 
evidence  itself  only  under  unfavorable  conditions.  The  hysteric 
state  manifests  itself  in  many  ways:  some  individuals  are  timid 
and  fearful,  whereas  others  are  bold  and  aggressive;  some  are 
changeable  and  inconsistent,  whereas  others  are  stubborn ;  some 
are  generous,  others  selfish — but  all  show  superficial  judgment, 
are  very  susceptible  to  external  or  internal  impressions,  are 
abnormally  suggestible,  strongly  emotional,  and  lack  ability 
to  exercise  control  over  their  emotions  and  actions.  In  some 
cases  they  seem  devoid  of  the  power  of  arresting  some  of  the 
reflex  bodily  functions.  These  individuals  are  usually  egotistic, 
crave  sympathy,  and  are  often  of  an  introspective  temperament, 
showing  a  marked  tendency  to  exaggerate  their  symptoms. 

Some  hysteric  persons  who  are  conscious  of  a  tendency  to 
emotional  outbreaks  may  succeed  in  controlling  the  attacks; 
in  other  individuals  the  hysteric  temperament  may  not  manifest 
itself.  In  both  of  these  groups  of  cases  any  untoward  con- 
dition, such  as  prolonged  exhausting  illness,  overindulgence  in 
alcohol,  shock,  severe  fright,  great  grief  or  sudden  joy,  may 
precipitate  an  attack  or  reveal  the  presence  of  a  hysteric  tem- 
perament. 

Those  who  are  afiflicted  with  this  peculiar  mental  temperament 
are  subject  to  attacks  that  may  be  of  short  or  of  long  duration, 
and  that  may  be  mild  or  severe.  Such  attacks  are  characterized 
by  disturbances  of  the  emotions  and  of  the  motor,  sensor}^, 
vasomotor,  secretory,  or  mental  functions.  Generally  more 
than  one  of  these  functions  are  affected,  although  it  is  quite 
possible  for  the  attack  to  be  characterized  by  either  an  increase 
or  a  decrease  of  the  normal  functions  of  any  one  of  these  elements. 
According  to  their  severity  and  duration  the  attacks  are  de- 
scribed as  minor  or  major.  Either  with  or  without  the  major 
or  minor  attacks,  or  following  or  preceding  an  attack,  there  may 


474  MANUAL   OF   NERVOUS   DISEASES 

occur  evidence  of  distrubance  of  the  bodily  or  mental  functions, 
which  may  last  a  long  or  a  short  time. 

As  the  result  of  an  emotional  or  physical  disturbance  an 
attack  may  develop  that  lasts  for  a  short  time,  and  that  is  not 
characterized  by  marked  loss  of  self-control.  In  these  minor 
attacks  the  individual  is  usually  restless,  may  be  apprehensive, 
feel  depressed,  has  a  choking  sensation,  a  peculiar  feeling  in  the 
throat  as  if  a  lump  were  there  which  can  neither  be  swallowed 
nor  brought  up  (the  globus  hystericus).  He  may  complain  of 
a  sense  of  weight  on  top  of  the  head,  pains  in  the  eyes  or  back, 
or  a  pain  as  if  a  sharp  object  were  being  driven  into  the  top 
of  the  head.  There  may  be  a  sense  of  extreme  weakness. 
Some  patients  are  seized  with  an  imperative  desire  to  cry  or  to 
laugh,  and  in  some  attacks  of  laughter  are  followed  by  spells  of 
weeping;  in  others  the  restlessness  increases  and  the  mental 
state  simulates  delirium.  The  attacks  may  cease  suddenly 
without  apparent  reason,  or  the  patient  may  fall  asleep  and 
awaken  in  a  normal  state,  or  under  treatment  the  attacks  may 
subside  gradually.  On  the  other  hand,  the  patient  may  have 
a  number  of  these  mild  attacks,  one  following  the  other  at  short 
interv^als. 

After  recovering  from  a  series  of  attacks  or  from  a  severe 
attack  the  patient  may  be  considerably  exhausted.  In  some 
individuals  these  minor  attacks  are  characterized  by  the  occur- 
rence of  severe  pain,  which  may  be  localized  or  diffuse,  may  last 
a  variable  length  of  time,  and  then  gradually  subside.  The 
pain  is  most  frequently  located  in  the  head  and  the  back  of 
the  neck. 

The  major  attacks  may  begin  with  restlessness,  emotional 
disturbances,  a  tendency  to  weep  or  to  laugh,  the  presence  of 
the  globus  hystericus,  etc.  In  some  cases  the  symptoms  may 
become  more  marked,  and  the  patient  may  scream,  become 
more  restless,  eventually  either  running  wildly  about  or  falling 
upon  the  ground  or  upon  some  convenient  place,  and  exhibiting 
violent  muscular  movements  or  becoming  rigid.  The  convulsive 
movements  exhibited  by  these  patients  are  always  extensive 
and  purposive  in  character:  they  kick,  bite,  strike  at  bystanders, 
scratch,  run  their  fingers  through  their  hair,  being  careful,  how- 


HYSTERIA  475 

ever,  not  to  pull  out  their  own  hair.  They  suck  their  gums  and 
lips  to  make  them  bleed  and  sometimes  expectorate  bloody 
saliva.  Their  contortions  and  movements  may  become  most 
violent.  Occasionally  the  individual  becomes  perfectly  rigid, 
ceases  to  breathe  for  a  few  seconds,  the  face  becoming  cyanotic; 
in  most  instances,  however,  the  face  is  flushed,  and  the  skin 
is  moist  or  covered  with  perspiration.  Not  infrequently  dur- 
ing these  seizures  the  patient  assumes  peculiar  attitudes — opis- 
thotonos; in  more  marked  cases  the  arc  de  circle  and  attitudes 
expressive  of  some  emotion  are  assumed. 

During  the  attack  the  patient  frequently  screams,  sings, 
laughs,  and  at  times  uses  very  profane  and  obscene  language. 
Some  patients  utter  meaningless  sounds,  as  if  they  were  speak- 
ing in  a  foreign  language.  There  may  be  a  perversion  of  con- 
sciousness, but  complete  unconsciousness  practically  never 
obtains,  as  these  individuals  usually  react  to  external  impres- 
sions. The  attacks  last  for  variable  lengths  of  time;  in  some 
they  are  of  only  a  half -hour's  duration,  or  even  less,  and  in 
others  the  attack  may  last  many  days.  In  some  the  attacks 
occur  only  at  infrequent  intervals,  and  then  apparently  follow 
some  exciting  cause;  in  others  the  attacks  occur  frequently 
without  any  definite  causative  condition.  The  attacks  may  be 
preceded  by  premonitory  symptoms,  but  ui  these  individuals 
the  warning  is  usually  variable,  and  generally  occurs  quite  a 
while  before  the  attack.  As  a  rule,  these  attacks  subside 
gradually  and  are  followed  by  a  period  of  marked  exhaustion 
and  gradual  recovery. 

In  both  the  major  and  the  minor  attacks  the  pupils  are 
usually  equally  dilated  and  react  to  light;  the  deep  reflexes  are 
generally  increased,  and  the  Babinski  sign  is  absent.  During 
the  attack  the  individual  does  not  injure  himself,  except  acci- 
dentally; for  example,  in  his  struggles  with  those  who  seek  to 
restrain  him  he  may  be  injured,  or  he  may  accidentally  injure 
himself  by  striking  against  some  object.  Following  the  attack 
he  usually  passes  a  large  quantity  of  very  pale  urine.  Instead 
of  gradually  recovering  after  an  attack,  some  individuals  may 
enter  a  state  of  delirium  that  may  last  for  several  days,  and 
then  gradually  subside,  when  recovery  sets  in. 


47^  MANUAL   OF   NERVOUS   DISEASES 

The  hysteric  attacks  may  vary  greatly  in  character;  in  some, 
the  attack  is  Hmited  to  loss  of  emotional  control,  at  times  ac- 
companied by  sobbing,  uncontrollable  weeping,  or  alternate 
laughing  and  weeping;  or  there  may  be  restlessness,  displays  of 
temper,  choking  sensations  in  the  throat,  etc.;  or  anxiety,  fear 
of  death,  pallor,  weakness,  profuse  perspiration,  tremor,  and 
pain,  or  vertigo,  dimness  of  vision,  ringing  in  the  ears,  a  feel- 
ing of  weakness,  may  be  the  symptoms  that  constitute  the 
attack. 

Hysteric  attacks  may  closely  simulate  major  epileptic  at- 
tacks, or  they  may  be  characterized  by  peculiarities  of  move- 
ments during  which  the  patient  acts  as  if  he  were  performing 
some  definite  act,  such  as  bowing  or  skipping,  or  he  may  sud- 
denly assume  an  attitude  or  an  expression  and  maintain  that 
for  a  longer  or  a  shorter  period. 

Attacks  that  closely  resemble  fainting  spells  may  occur; 
usually  tremor  is  present,  either  in  the  hands  or  in  the  face;  the 
pulse  remains  unaffected.  ^ 

Attacks  of  sleep  may  follow  an  emotional  disturbance  or 
several  of  the  ordinary  hysteric  seizures.  The  onset  of  these 
attacks  may  be  sudden  or  gradual,  and  they  may  last  from  a 
very  short  time  to  hours,  days,  or  months,  terminating  sud- 
denly in  a  convulsive  attack  or  by  gradual  stages.  During  this 
state  the  patient  appears  as  if  he  were  sleeping  naturally. 
Although  these  patients  are  apparently  unconscious,  they  are 
generally  able  to  tell  what  has  taken  place  during  this  period. 
The  pulse-rate  may  be  somewhat  slowed;  the  pupils  react  to 
light;  the  respiration  is  generally  somewhat  slower.  In  this 
state  the  individual  may  be  completely  relaxed,  but  there  is 
a  tendency  to  fall  into  a  cataleptic  condition. 

Somnambulistic  Attacks. — After  some  emotional  disturbance 
or  hysteric  attack  the  patient  suddenly  acts  as  if  he  were  affected 
with  some  abnormal  mental  state.  He  may  remain  in  this  con- 
dition for  a  considerable  length  of  time,  during  which  he  seems 
possessed  of  another  character  and  acts  in  accordance  with  the 
same.  While  in  this  state  his  physical  actions  correspond  to 
his  newly  acquired  character.  When  the  spell  has  passed  off, 
the  individual  not  infrequently  finds  himself  amid  new  sur- 


HYSTERIA 


477 


roundings,  and  has  no  recollection  of  the  events  that  have  taken 
place  during  the  attack.  In  succeeding  attacks  he  may  recall 
everything  that  transpired  during  previous  seizures. 

Attacks  of  this  sort  frequently  give  rise  to  conditions  that  are 
known  as  double  personality. 

Following  a  major  or  a  minor  hysteric  attack,  a  terrifying  ex- 
perience, shock  accompanied  by  emotional  disturbance,  fear, 
anxiety,  disappointment,  etc.,  there  may  be  disturbances  of 


A  B 

Fig.  152. — A,  Hysteric  paralysis;  B,  making  effort  to  raise  arm. 


motion  and  sensation,  and  of  the  vasomotor,  secretor}^,  or 
mental  functions.  These  have  no  anatomic  basis,  and  are  the 
result  of  a  disturbed  activity,  either  increased  or  decreased,  of 
the  subconscious  cerebral  centers.  These  abnormalities  of 
functions  are  in  some  instances  capable  of  being  reproduced 
voluntarily,  but  more  frequently  they  cannot  be  voluntarily 
reproduced  nor  sustained  to  the  extent  to  which  they  occur. 
Disturbance  of  the  Motor  Functions. — Paralysis  or  contrac- 


478  MANUAL   OF   NERVOUS   DISEASES 

tures,  or  paralysis  and  contractures  (Fig.  152),  are  of  frequent 
occurrence.  The  paralysis  may  affect  the  entire  limb,  giving 
rise  to  a  monoplegia,  or  it  may  affect  the  entire  side  of  the  body, 
causing  a  hemiplegia.  It  may  affect  both  lower  extremities, 
causing  a  paraplegia,  or  may  involve  all  four  extremities.  In 
some  cases  the  paralysis  is  limited  to  only  a  segment  of  the 
limb,  usually  involving  the  peripheral  portion  of  the  limb, 
although  at  other  times  the  proximal  part  of  the  limb  is  affected. 
Instead  of  a  complete  inability  to  move  all  or  a  part  of  the  body, 
in  some  cases  a  weakness  exists.  Not  infrequently  automatic 
and  customary  movements  are  carried  out  with  the  normal 
strength,  but  when  such  patients  are  requested  to  perform  some 
voluntary  movement,  a  weakness  is  found  to  exist.  Examina- 
tion reveals  the  fact  that  although  all  the  muscles  are  well 
contracted,  little  or  no  effort  is  exerted.  When  a  complete 
paralysis  exists,  the  individual  states  that  he  is  unable  to  move 
the  affected  parts,  and  when  requested  he  makes  no  effort  to  do 
so.  The  paralysis  in  these  cases  is  usually  of  the  flaccid  type, 
but  the  muscle  tone  remains  normal  and  the  deep  reflexes  are 
usually  increased.  The  individual  often  unconsciously  moves 
the  part  of  the  body  in  which  he  asserts  that  paralysis  exists. 
The  paralysis  or  weakness  is  generally  limited  to  the  ex- 
tremities. 

In  some  cases,  instead  of  a  paralysis  or  a  weakness  being 
present,  the  muscular  movements  are  retarded.  Voluntary 
movements  carried  out  as  the  result  of  commands  are  performed 
slowly,  and  after  a  distinct  interval,  as  if  the  patient  had  diffi- 
culty in  associating  the  idea  of  movement  with  motor  activities. 

In  other  patients,  instead  of  a  loss  or  decrease  of  motion, 
abnormalities  of  movement  occur.  These  may  take  the  form 
of  a  contracture,  under  which  condition  ah  extremity,  part  of 
an  extremity,  the  trunk,  or  the  facial  muscles  are  held  con- 
stantly in  a  rigid  position. 

Contractures  result  in  positions  of  the  affected  portion  of  the 
body  that  can  be  assumed  voluntarily,  and  are  further  charac- 
terized by  the  fact  that  they  are  usually  increased  on  attempts 
to  overcome  them,  and  likewise  by  the  fact  that  they  disappear 
during  sleep. 


HYSTERIA  479 

Tremors  and  Other  Abnormal  Movements. — ^Tremors  are  usu- 
ally coarse,  but  may  be  slow  or  rapid.  They  are  generally 
increased  upon  voluntary  movement  and  during  excitement. 
As  a  rule,  they  are  jerky  in  character,  and  often  disap- 
pear when  the  patient  is  at  rest  or  does  not  know  that  he 
is  being  observed.  Grosser  abnormalities  of  movement  may 
also  occur  and  may  be  choreiform  in  character,  or  movements 
may  occur  involving  the  whole  body;  thus  the  patient  may  go 
through  swimming  movements,  dancing  movements,  sucking 
movements,  etc. 

Astasia-ahasia  is  a  peculiar  motor  condition  seen  to  occur  in 
hysteric  individuals.  In  this  condition  the  individual  can, 
while  sitting  or  lying,  perform  movements  with  his  limbs  with 
a  normal  amount  of  power,  but  is  unable  to  stand  or  to  walk. 
When  the  patient  is  helped  to  his  feet,  he  may  either  collapse, 
or,  after  making  one  or  two  efforts  to  walk,  he  sways  from  side 
to  side  and  staggers  and  falls. 

Among  the  commoner  forms  of  abnormalities  of  movement 
are:  ^Singultus,  which  is  repeated  sw^allowing,  generally  fol- 
lowed by  eructation  and  rumbling  noises  in  the  abdomen;  the 
eructations  and  rumbling  in  the  intestines  are  the  result  of  the 
swallowing  of  air;  hiccoughing;  yawning;  sneezing,  which  may 
be  repeated  for  hours  at  a  time;  abnormalities  of  respiration 
in  which  the  breathing  is  rapid  and  irregular;  somewhat  less 
common  are  hysteric  blepharospasm  and  hysteric  coughing,  the 
latter  being  hoarse,  loud,  and  frequently  repeated.  At  other 
times  the  patient  utters  peculiar  noises,  and  there  is  an  inability 
to  swallow;  this  may  be  due  to  a  hysteric  spasm  of  the  pharynx 
and  the  esophagus.  Hysteric  aphonia  is  a  condition  in  w^hich 
the  patient  more  or  less  suddenly  loses  his  voice,  being  unable 
to  speak  above  a  whisper,  and  in  some  cases  being  unable  to 
utter  a  sound. 

Sensation,  like  motion,  may  be  lost,  increased,  or  perverted. 
One  of  the  commonest  complaints  in  hysteria  is  of  pain,  which 
may  be  said  to  be  constantly  present,  or  to  occur  in  paroxysms 
and  involve  any  portion  of  the  body.  Headache  is  very  fre- 
quent. These  individuals  often  complain  of  sensitiveness  of 
the  scalp;  of  very  acute  pains  in  circumscribed  areas  of  the  head 


48o 


MANUAL   OF  NERVOUS   DISEASES 


and  of  occipital  headache;  pain  radiating  through  the  head  into 
the  eyes;  drawing  pain  in  the  back  of  the  head;  headache  Hmited 
to  one-half  of  the  head,  etc.  Pain  of  a  neuralgic  character; 
pain  in  the  back;  pain  limited  to  one-half  of  the  body;  pain  in 
the  breast  (mastodynia) ;  pain  described  as  existing  in  various 
organs;  pain  in  the  extremities;  pain  in  the  lower  end  of  the 

spine;  pain  in  the  joints;  pain 
simulating  angina  pectoris,  etc., 
are  also  frequently  complained  of. 
These  painful  states  are  charac- 
terized by  the  fact  that  careful 
examination  does  not  reveal  any 
organic  cause  for  their  presence. 
They  may  be  very  persistent,  last- 
ing for  weeks  and  months.  They 
seem  to  have  little  effect  upon  the 
patient's  general  condition,  and  are 
markedly  influenced  by  the  mental 
state  of  the  patient.  Sometimes 
hyperesthesia  of  the  skin  and  vaso- 
motor disturbances  occur  in  these 
painful  areas. 

Paresthesias  varying  in  type  are 
also  frequently  complained  of  in 
hysteria,  as  are  also  hyperesthesia, 
numbness,  tingling,  formication, 
etc.  The  distribution  of  these 
paresthesias  may  vary,  like  the 
distribution  of  pain  from  a  local- 
ized area  of  one  portion  of  the 
body  to  a  more  or  less  generalized 
distribution. 

Hysterogenic  Zones. — ^These  are 
circumscribed  areas  that  are  usu- 
ally hyperesthetic,  and  give  rise  to  pain  when  pressed  upon. 
These  zones  may  be  situated  in  different  parts  of  the  head,  in 
the  axillary  line,  in  the  submammary  region,  subclavicular 
region,  over  the  sternum,  in  the  lateral  hypogastric  region, 


Fig.  153. — Hysterogenic  zones. 


HYSTERIA  481 

especially  over  the  ovaries,  in  the  epigastric  region,  and  over  the 
site  of  the  apex-beat  of  the  heart  (Fig.  153). 

The  special  senses  may  also  be  hyperesthetic,  the  patient 
complaining  of  extreme  sensitiveness  to  light,  to  sound,  to  smell, 
etc.,  or  there  may  be  discomfort  in  using  the  eyes.  This  dis- 
comfort may  be  experienced  only  under  certain  conditions,  such 
as  on  reading  or  upon  looking  at  near  objects  or  at  colored  ob- 
jects, etc.  Some  patients  complain  of  auditory  sensitiveness 
only  under  certain  conditions,  some  sounds  causing  great  dis- 
comfort, whereas  other  pass  unnoticed. 

Decrease  or  loss  of  sensation  is  also  common  in  hysteria. 
The  distribution  of  the  anesthesia  is  never  confined  to  areas 
supplied  by  nerves  or  nerve  plexuses  or  by  spinal-cord  seg- 
ments: it  frequently  affects  half  of  the  body,  being  sharply 
marked  off  in  the  middle  line,  and  sometimes  involving  the  entire 
body.  It  may  be  limited  to  one  arm  or  to  one  hand,  the  head 
or  the  face,  to  one  leg  or  to  one  foot,  both  feet,  etc.  It  is  limited 
to  areas  of  the  body  other  than  those  obsers^ed  in  organic  dis- 
eases, the  areas  of  anesthesia  being  usually  sharply  defined. 
As  a  rule,  they  can  be  transferred  from  one  side  of  the  body  to 
the  other,  and  be  made  to  appear  and  to  disappear  under  ap- 
propriate suggestion.  The  mucous  membranes  may  also  be 
affected.  When  sensation  is  involved,  pain,  tactile,  and  tem- 
perature senses  are  all  usually  affected;  the  degree  of  involve- 
ment may  vary  from  slight  reduction  of  sensibility  to  complete 
anesthesia.  In  some  cases  there  may  be  dissociation  of  sensa- 
tion, there  being  loss  of  the  sense  of  pain  without  impairment 
of  the  sense  of  touch  (Fig.  154). 

The  special  senses  may  also  show  a  similar  change.  Among 
the  most  common  and  important  are  the  visual  disturbances. 
In  some  cases  there  is  a  diminution  in  the  acuteness  of  vision, 
with,  at  times,  a  concentric  narrowing  of  the  visual  field.  Rarely 
a  bilateral  hysteric  blindness  is  present.  In  these  individuals 
the  pupillary  reflex  is  retained,  and  the  individuals  find  their 
way  about  with  comparative  ease,  avoiding  obstacles.  Very 
frequently  a  hysteric  ptosis  is  combined  with  the  hysteric  amau- 
rosis. Decrease  or  loss  of  the  sense  of  smell,  sense  of  taste,  and 
sense  of  hearing  may  also  occasionally  occur.  Hysteric  pa- 
31 


482 


MANUAL   OF   NERVOUS   DISEASES 


tients  are  frequently  ignorant  of  the  sensory  disturbances,  and 
are  made  conscious  of  them  only  at  the  time  of  the  examina- 
tion. 

Reflexes. — ^The  superficial  reflexes  may  be  decreased  or  abol- 
ished or  remain  unaffected.    The  tendon  reflexes  are  usually 


Fig.  154. — Distribution  of  anesthesia  in  hysteria. 

increased.  The  pharyngeal  and  palpebral  reflexes  disappear 
if  there  is  decreased  sensation  in  these  parts.  The  cardiac  and 
respiratory  reflexes  to  painful  cutaneous  stimuU  are  retained, 
even  when  an  anesthetic  zone  is  irritated. 


HYSTERIA  483 

Vasomotor  and  circulatory  disturbances  frequently  occur; 
in  patients  with  hysteric  anesthesia  often  a  needle-prick  does 
not  cause  bleeding,  and  sometimes  operations  upon  the  super- 
ficial tissues  can  be  performed  with  little  loss  of  blood.  Parox- 
ysms of  cardiac  palpitation,  with  rapid  pulse,  rapid  changes  in 
color,  sudden  pallor,  and  flushing  commonly  occur.  Hard, 
inelastic,  circumscribed  swellings  may  appear  that  do  not  pit 
upon  pressure,  and  that  may  be  pale  or  bluish  in  color. 

Disturbance  of  the  Secretions. — ^There  may  be  a  marked  in- 
crease or  decrease  in  the  amount  of  saliva  secreted,  and  the 
amount  of  urine  voided  may  be  greatly  increased.  As  a  rule, 
large  quantities  of  urine  are  voided  after  an  attack. 

Gastro-intcstinal  Disorders. — Some  patients  complain  of  com- 
plete loss  of  appetite  and  a  distaste  for  all  kinds  of  food.  These 
symptoms  may  be  present  only  during  attacks  or  may  be  per- 
sistent. Occasionally  there  is  marked  increase  in  the  appetite, 
and  in  some  individuals  loss  of  appetite  alternates  with  marked 
increase  of  appetite.  If  a  loss  of  appetite  with  refusal  of  food 
persists  for  any  length  of  time  the  patient's  nutrition  becomes 
affected  and  the  condition  is  attended  with  a  certain  amount  of 
danger. 

Hysteric  vomiting  is  a  somewhat  common  symptom.  The 
food  is  generally  vomited  immediately  after  it  is  taken.  As  a 
rule,  the  appetite  remains  good,  and  the  individual  does  not 
become  emaciated.    This  symptom  may  be  very  persistent. 

Protrusion  of  the  abdomen,  caused  by  distention  of  the  in- 
testines with  gas  and  by  a  relaxed  condition  of  the  abdominal 
muscles,  and  loud  rumbling  noises  in  the  intestines  are  fre- 
quently present  in  hysteric  individuals.  Constipation  may 
continue  for  days,  or  diarrheal  attacks  may  be  present. 

Trophic  disorders  are  certainly  uncommon;  they  may  occur 
as  the  result  of  prolonged  pressure  in  hysteric  contractures,  but 
are  usually  of  traumatic  origin,  and  are  sometimes  produced 
voluntarily. 

Hysteric  fever  is  not  a  common  symptom,  and  when  it  does 
occur  the  greatest  care  should  be  taken  to  exclude  organic  dis- 
ease. The  fever  may  be  continuous  or  intermittent  in  type, 
the  temperature  ranging  from  100°  to  111°  F.     These  febrile 


484  MANUAL   OF  NERVOUS   DISEASES 

attacks  are  usually  unaccompanied  by  alterations  in  the  pulse 
and  respiration. 

In  my  experience  the  rise  in  temperature  has  not  been  ac- 
companied by  an  increased  warmth  of  the  skin  or  mucous  mem- 
branes; but  was,  rather,  the  result  of  manipulation  of  the 
thermometer  on  the  part  of  the  patient.  One  must,  however, 
admit  the  possibility  of  the  occurrence  of  a  true  hysteric  fever. 

Mental  Symptoms. — ^The  mental  faculties  are  generally  un- 
impaired. Hysteria  occurs  more  frequently  in  intelligent  and 
sensitive  individuals  than  in  the  stupid  and  phlegmatic.  Hys- 
teric individuals  are  usually  very  impressionable,  their  thoughts 
being  more  or  less  self-centered,  and  directed  only  toward 
matters  in  which  they  are  interested;  this  frequently  gives  rise 
to  an  inattention  to  other  matters,  with  corresponding  neglect. 
The  memory,  as  a  rule,  does  not  show  any  marked  impairment, 
but  as  the  result  of  inattention  it  apparently  may  be  weakened. 

Some  individuals  find  certain  subjects  disagreeable,  and  ideas 
may  be  fixed  in  the  memory  with  an  increased  tenacity,  and 
be  more  or  less  persistently  present.  In  others  there  may  be  an 
apparent  loss  of  memory  for  special  events  or  times.  These 
disturbances  of  memory  may  occur  periodically,  and  during 
these  periods  the  patient  may  remember  the  events  that  occurred 
at  a  preceding  period,  but  during  the  intervals  is  entirely  amnesic 
for  events  and  occurrences  that  have  taken  place  during  the 
attack. 

These  memory  defects  are  especially  apt  to  follow  repeated 
hysteric  attacks. 

Catalepsy  is  a  condition  that  is  characterized  by  rigidity  of  the 
extremities.  This  rigidity  may  be  general  or  limited,  and  may 
result  in  the  patient  remaining  in  the  position  in  which  he  is 
placed  for  considerable  lengths  of  time.  Attempts  to  move 
the  limbs  are  met  with  slight  resistance;  the  sensibilities  are 
usually  decreased  or  abolished;  the  individual  is  not  uncon- 
scious, but  is  generally  in  a  dreamy  state. 

The  pupillary  reflexes  are  always  retained.  The  patient  may 
remain  in  this  state  for  hours,  days,  or  weeks.  This  condition 
usually  follows  some  mental  excitement  or  may  occur  after  a 
hysteric  attack. 


HYSTERIA  485 

It  is  important  to  differentiate  this  condition  from  dementia 
praecox ;  this  can  be  done  only  after  a  very  careful  consideration 
of  the  history  and  on  prolonged  observation. 

Course. — In  the  great  majority  of  cases  the  disease  runs  a 
chronic  course  and  is  subject  to  many  variations.  Generally 
intervals  occur  during  which  the  individual  is  apparently  normal. 
The  character  of  the  attack  may  vary  from  time  to  time,  and 
there  may  be  complete  disappearance  of  some  of  the  symptoms 
with  the  appearance  of  others.  In  certain  cases,  particularly 
those  occurring  during  childhood,  there  is  a  predominance  of 
some  special  symptoms,  and  sometimes  only  one  symptom  may 
be  present. 

The  disease  may  develop  gradually  or  the  onset  may  be 
acute,  beginning  with  subjective  symptoms,  to  which  are  added, 
from  time  to  time,  objective  manifestations,  which  appear 
particularly  after  sudden  emotional  disturbances  or  injury. 
The  disease  manifests  itself  most  frequently  for  the  first  time 
between  the  twelfth  and  the  twenty-fifth  year,  and  generally 
following  some  form  of  emotional  disturbance.  Recurring  at- 
tacks appear  which  vary  in  severity  and  in  character,  and  occur 
at  irregular  intervals.  They  are  usually  associated  wdth  emo- 
tional disturbances,  apprehension,  or  fear,  either  of  external  or 
of  internal  origin,  and  the  symptoms  vary.  The  condition  may 
last  for  many  years.  In  a  large  number  of  cases  the  symptoms 
become  less  severe  and  sometimes  disappear  after  the  fiftieth 
year. 

Prognosis. — ^The  prospects  of  recovery  are  better  if  the  patient 
has  confidence  in  the  one  who  administers  the  treatment,  and 
if  there  is  an  incentive  and  a  determination  to  recover.  The 
prognosis  also  depends  on  the  possibility  of  removing  the  cause, 
or  upon  the  ability  of  the  patient  to  resign  himself  to  existing 
conditions. 

In  those  individuals  in  whom  a  marked  hereditar}^  tend- 
ency exists  and  who  present  stigmata  of  degeneration  the 
probability  of  recovery  is  slight,  whereas  in  those  in  whom 
there  is  an  absence  of  a  neuropathic  hereditary  tendency  and 
in  whom  the  hysteric  symptoms  appear  only  after  some  acute 
condition  a  very  favorable  prognosis  may  be  given.    When 


486  MANUAL   OF   NERVOUS   DISEASES 

hysteric  symptoms  are  combined  with  great  anxiety,  hypo- 
chondriasis, neurasthenic  states,  or  psychosis  the  outlook  is 
extremely  unfavorable. 

Under  proper  treatment  the  vast  majority  of  cases  recover 
from  the  hysteric  attack,  and  there  may  be  total  disappearance 
of  the  hysteric  symptoms.  In  some  cases,  even  under  the  most 
expert  treatment,  hysteric  symptoms  persist  for  many  years. 
The  prognosis  as  to  recurrence  of  attacks  or  of  symptoms  is 
unfavorable,  owing  to  the  fact  in  these  individuals  a  peculiar 
mental  state  exists  that  predisposes  them  to  a  recurrence  of  the 
condition.  There  are,  however,  many  individuals  who,  under 
proper  treatment,  can  be  brought  to  realize  their  weakness, 
who  are  willing  and  anxious  to  avoid  further  attacks,  and  who 
finally  succeed  in  overcoming  this  tendency  and  remain  per- 
manently free  from  the  symptoms. 

Diagnosis. — ^The  diagnosis  must  be  made  by  exclusion. 
Hysteria  may  resemble  any  of  the  organic  physical  or  nervous 
diseases,  and  it  is,  therefore,  necessary  to  make  a  most  careful 
examination  of  the  internal  organs  and  of  the  nervous  system. 

In  differentiating  h^^steric  from  organic  diseases  it  is  extremely 
important  to  examine  the  fundus  of  the  eye  and  to  detect  any 
pupillary  disturbances;  the  distribution  and  character  of  paral- 
yses and  of  sensory  disturbances ;  the  presence  or  absence  of  the 
deep  and  the  superficial  reflexes;  the  presence  or  absence  of 
bowel  and  bladder  disturbances;  the  nature  of  speech  disturb- 
ances; the  character,  duration,  and  sequelae  of  convulsive 
attacks;  the  reaction  of  symptoms  to  external  influences,  etc., 
as  guides  to  a  correct  diagnosis. 

If  a  proper  examination  has  been  made,  error  is  possible  only 
under  the  most  unusual  conditions.  It  is  important  to  dif- 
ferentiate hysteria  from  such  diseases  as  neurasthenia,  epi- 
lepsy, edementia  praecox,  and  from  conditions  whose  principal 
symptom  is  pain,  as,  for  example,  neuralgia,  headache,  painful 
joints,  angina  pectoris,  etc. 

In  differentiating  hysteria  from  neurasthenia  the  following 
points  are  important: 


HYSTERIA 


487 


Onset: 
Course: 

Seizure: 

Effect  of  effort: 

Intervals: 

Sensory   disturb- 
ances: 
Painful  areas: 

Contractures: 
Motor      disturb- 
ances: 


Visual  fields: 
Mental  state: 
Emotional  state: 


Hysteria, 

Generally  sudden. 

Changeable,  irregular,  and 
paroxysmal. 

Convulsive  attacks,  crying 
or  laughing  spells,  etc. 

Frequently  dispelled  or  de- 
creased. 

Of  comparatively  normal 
capacity. 

Definite  areas  of  anes- 
thesia. 

Hysterogenic  zones  sensi- 
tiv^e. 

Frequently  present. 

Paralysis,  gross  abnormal- 
ity of  movements,  chok- 
ing sensation,  etc.,  often 
present. 

Frequently  contracted. 

Exaggerated  suggestibility. 

Emotional  mobility,  wdth 
defective  emotional  in- 
hibition. 


Neurasthenia. 

Gradual,  unless  traumatic- 
More  or  less  monotonous. 

Absent. 

Aggravated     or     rendered 

worse. 
Uniform  incapacity. 

Absent. 

General  sensitiveness. 

Absent. 

Complaint  of  general  weak- 
ness. 


Undisturbed. 
Pathologic  fatigue. 
Uniform  emotional  depres- 
sion. 


In  neurasthenia  there  is  a  history  either  of  decreased  mental 
and  physical  power,  dating  back  to  earliest  childhood,  or  of 
oven\^ork  under  unfavorable  conditions.  In  hysteria  there  is 
a  history  of  lack  of  emotional  control,  of  egotism,  of  peculiar 
attacks,  and  of  pathologic  suggestibility  during  childhood  or 
early  adult  life,  or  of  some  emotional  shock,  disappointment, 
fear,  failure,  etc.,  preceding  the  illness. 

The  differentiation  between  epilepsy  and  hysteric  attacks 
is  discussed  under  Epilepsy. 

In  distinguishing  hysteric  painful  seizures  from  such  conditions 
as  neuralgia,  examination  reveals  the  fact  that  in  hysteria  the 
pain  is  rarely  confined  to  the  area  supplied  by  a  nerve;  in  hys- 
teria nerve  pressure-points  are,  as  a  rule,  not  so  sensitive  as  in 
neuralgia;  in  hysteria  tenderness  is  diffuse,  whereas  in  neuralgia 
it  is  confined  to  ner\^e  pressure-points  or  to  the  area  of  distri- 
bution of  the  affected  nerve.  In  hysteria  the  pain  can  be  in- 
fluenced by  mental  suggestion  and  the  attacks  are  usually 
dependent  upon  some  form  of  excitement. 

In  distinguishing  the  headache  of  hysteric  attacks  from  a  true 


488  MANUAL  OF  NERVOUS  DISEASES 

headache  a  careful  examination  is  always  required:  in  hysteria 
the  pain  is  apt  to  be  limited  to  circumscribed  areas,  and  is,  as 
a  rule,  dependent  upon  some  form  of  emotional  disturbance; 
it  comes  on  more  or  less  suddenly,  and  frequently  disappears 
with  equal  suddenness;  prolonged  pain  does  not  affect  the 
general  physical  condition,  as  does  the  prolonged  and  severe 
pain  that  is  the  result  of  organic  disease. 

The  differentiation  between  hysteric  painful  joints  and 
hysteric  pains  about  the  heart  and  pain  in  the  joints  as  the 
result  of  organic  disease  and  of  organic  cardiac  affections  at- 
tended by  pain  can  usually  be  made  if  one  takes  into  considera- 
tion the  absence  of  physical  findings  and  the  history  of  a  pre- 
ceding emotional  disturbance  in  the  former  case,  and  the  pres- 
ence of  physical  findings  and  the  history  of  some  preceding  dis- 
ease and  emotional  disturbance  occurring  after  the  pain  in  the 
latter  case.  The  differentiation  between  the  early  manifes- 
tations of  dementia  praecox  and  hysteria  is  in  some  cases  ex- 
tremely difficult.  In  dementia  praecox  there  is  a  history  of  a 
previous  normal  mental  condition  or  a  peculiarity  of  mental 
temperament:  in  hysteria  there  is  a  history  of  emotional  hys- 
teric temperament;  in  dementia  praecox  the  actions  are  some- 
what purposeless,  whereas  in  hysteria  they  seem  to  follow  a 
definite  purpose — that  of  impressing  those  with  whom  the  in- 
dividual comes  in  contact. 

In  dementia  praecox  there  are  more  or  less  indifference, 
marked  irritability,  and  frequently  ideas  of  reference;  in  hys- 
teria the  individual  craves  sympathy,  anger  alternating  with 
affection,  and  the  individual  blames  his  condition  on  an  un- 
fortunate combination  of  circumstances,  but  not  on  others. 

Treatment. — Persons  in  whom  there  is  a  history  of  a  heredi- 
tary tendency  to  nervous  disease  or  who  show  evidence,  early  in 
life,  of  a  hysteric  temperament,  should  have  their  lives  so  ordered 
that  they  are  assured,  as  far  as  possible,  of  a  normal  physical 
development.  Their  education  should  be  so  directed  that  they 
may  acquire  altruistic  tendencies,  and  they  should  be  taught 
the  value  of  self-control. 

In  the  early  years  of  life  much  can  be  done  for  these  children : 
if  the  mother  is  hysteric  or  nervous,  she  may  set  a  very  bad 


HYSTERIA  489 

example  for  the  child  by  speaking  of  her  own  illness  or  by  com- 
plaining in  the  presence  of  the  child.  Undue  importance  must 
never  be  given  to  the  child's  complaints.  Every  effort  should 
be  made  to  teach  it  self-control.  The  child's  attention  and 
interest  should  be  directed  toward  external  objects;  thus  it 
should  be  encouraged  to  obser\'e  the  phenomena  of  nature  and 
be  interested  in  outdoor  sports.  The  child  should  be  protected 
from  excitement,  and  the  reading  should  be  carefully  supervised. 
It  is  often  advisable  to  separate  the  child  from  the  home  con- 
ditions and  place  it  amid  new  surroundings.  Careful  physical 
examination  should  be  made,  and  all  physical  defects  or  ill- 
nesses should  receive  proper  treatment.  The  diet  should  be 
regulated,  and  should  consist  of  simple,  easily  digested,  and 
nourishing  food.     Alcohol  should  be  strictly  interdicted. 

The  occupation  of  an  individual  with  a  hysteric  tempera- 
ment should  be  carefully  selected,  and  should  be  one  as  free  as 
possible  from  worry,  strain,  and  emotional  excitement. 

The  treatment  of  the  hysteric  state  that  has  already  de- 
veloped is  at  times  very  simple,  and  at  other  times  extremely 
difficult. 

Before  undertaking  the  treatment  of  this  condition  it  is 
necessary"  to  make  a  thorough  and  careful  examination.  This 
is  done  for  two  reasons :  To  discover  the  presence  of  any  physical 
or  mental  abnormality  that  may  require  treatment,  and  to  gain 
the  patient's  confidence;  the  latter  is  a  most  important  aid  in 
carrying  out  the  treatment.  It  is  usually  necessar}'  to  remove 
these  individuals  from  their  accustomed  environment,  and  in 
the  more  serious  cases  complete  isolation  from  family  and 
friends  is  absolutely  necessar\\ 

The  Treatment  of  Hysteric  Symptoms. — Having  gained  the 
patient's  confidence,  and  ha\'ing  placed  him  amid  favorable 
surroundings,  it  is  important  to  direct  the  treatment  to  the 
relief  of  his  s}Tnptoms.  As  these  symptoms  are  entirely  psychic, 
their  removal  is  possible  only  by  influencing  the  mind  of  the 
patient.  He  should  be  assured  that  the  illness  is  not  serious, 
and  in  many  cases  a  frank  ex-planation  of  the  cause  of  the  symp- 
toms and  an  effort  to  arouse  the  cooperation  of  the  patient  are 
sufficient  to  bring  about  an  improvement.      There  are  many 


490  MANUAL  OF  NERVOUS  DISEASES 

patients,  however,  who,  during  the  earlier  stage  of  the  treat- 
ment, are  incapable  of  facing  their  illness  frankly,  or  are  unwill- 
ing to  do  so.  Such  individuals  must  be  relieved  of  their  symp- 
toms and  must  gradually  be  brought  to  a  mental  state  in  which 
they  will  cooperate  with  the  physician;  this  can  be  brought 
about  with  the  help  of  drugs  or  of  some  physical  measures, 
such  as  electricity,  hot  or  cold  packs,  the  cautery,  etc.  The 
nature  of  the  drug  or  the  physical  means  one  employs  is  of  no 
importance,  provided  its  use  is  accompanied  by  the  suggestion, 
on  the  part  of  the  physician,  and  the  hopeful  attitude,  on  the 
part  of  the  patient,  that  a  favorable  result  may  be  expected. 
It  is  better  to  employ  small  doses  of  aromatic  substances,  such 
as  tincture  of  valerian,  tincture  of  asafetida,  etc.,  or  small 
doses  of  the  bromids,  frequently  repeated,  than  larger  doses  at 
more  infrequent  intervals. 

Treatment  of  Anesthesia. — ^This  is  often  markedly  benefited 
by  the  application  of  the  faradic  current  through  a  metal  brush, 
or  by  the  spark  electrode ,  from  a  static  apparatus.  These 
applications  must,  of  course,  be  accompanied  by  the  suggestion 
or  statement  of  the  physician  that  they  will  be  effective.  At 
times  the  internal  administration  of  drugs,  when  accompanied 
by  the  assurance  that  relief  will  follow,  results  favorably. 
Painful  conditions,  such  as  headache,  backache,  neuralgia,  etc., 
may  be  relieved  by  inducing  counterirritation,  as  by  mustard 
foot-baths  or  the  cautery,  rubbing  with  liniments,  either  locally 
or  at  a  distance  from  the  seat  of  pain. 

Static  electricity,  the  violet-ray,  massage,  the  galvanic  cur- 
rent,— using  the  constant  pole  over  the  painful  areas, — or  even 
the  faradic  current  m^ay  be  of  value  when  accompanied  by 
proper  suggestion. 

In  prescribing  drugs  for  painful  conditions  it  is  best  to  give 
frequent  repeated  small  doses.  At  first  tincture  of  valerian, 
given  in  doses  of  5  drops  every  two  hours,  or  potassium  or 
sodium  bromid,  5  grains  every  two  hours,  may  be  prescribed. 
If  these  remedies  fail,  phenacetin  or  aspirin  in  small  doses  should 
be  given.  In  many  cases  a  placebo  will  be  as  effective  as  any 
of  the  aforenamed  drugs.  Morphin  and  chloral,  and  drugs  of  a 
similar  nature,  should  always  be  avoided. 


HYSTERIA  491 

Difficulty  in  swallowing,  or  dysphagia,  may  be  relieved  by 
gargling,  the  passing  of  a  stomach-tube,  or  the  application  of 
the  faradic  or  the  galvanic  current  to  the  neck.  At  times  pain- 
ful conditions  are  relieved  by  the  giving  of  an  emetic  and  the 
production  of  vomiting.  Hysteric  nausea,  vomiting,  eructa- 
tions, etc.,  may  be  relieved  by  changing  the  diet,  applying  coun- 
terirritation  over  the  stomach,  and  the  application  of  the  faradic 
or  the  galvanic  current  to  the  abdominal  wall;  sometimes  it  is 
necessary  to  apply  the  galvanic  or  the  faradic  current  by  means 
of  an  intragastric  electrode. 

If  drugs  are  used,  it  is  advisable  to  administer  them  in  the 
smallest  possible  doses;  thus  the  giving  of  i  or  2  drops  of 
almost  any  drug,  if  accompanied  by  the  proper  suggestion,  is 
more  apt  to  yield  a  favorable  result  than  the  administration  of 
larger  doses. 

Paralytic  conditions  are  best  treated  by  persuasion,  sugges- 
tion, and  passive  movements;  if  these  fail,  various  physical 
means  should  be  employed,  such  as  hot  and  cold  sponges,  coun- 
terirritation,  massage,  and  electricity. 

It  is  most  important  to  encourage  these  patients  and  to  have 
them  make  efforts  to  use  the  affected  parts  as  soon  as  possible. 
The  treatment  of  contractures  and  abnormalities  of  movement 
is  the  same  as  the  treatment  of  paralysis,  but  must,  of  course,  be 
accompanied  by  different  suggestions. 

In  treating  hysteric  aphonia  or  a  hysteric  cough,  in  addition 
to  the  measures  enumerated  above,  it  may  be  necessary  to 
apply  local  treatment  to  the  throat  or  larynx,  always,  of  course, 
accompanied  by  suggestion. 

Treatment  of  Hysteric  Attacks. — ^The  attacks  can  sometimes 
be  avoided  by  applying  pressure  upon  some  particular  part  of 
the  body.  If  an  attack  has  set  in,  it  is  advisable  to  remove  the 
patient  to  a  quiet  room,  excluding  every  one  but  the  person 
who  is  to  have  charge  of  the  patient.  Sometimes  the  applica- 
tion of  cold  water  to  the  patient's  face,  the  inhalation  of  spirits 
of  ammonia,  or  the  giving  of  a  small  dose  of  aromatic  spirits  of 
ammonia  may  terminate  the  attack.  In  other  cases  the  admin- 
istration  of  medicaments   having   a   disagreeable    taste,   fre- 


492  MANUAL   OF  NERVOUS   DISEASES 

quently  repeated,  is  efficient.  It  is  most  unwise  to  struggle 
with  the  patient  or  to  attempt  to  restrain  him.     . 

Counterirritation  by  means  of  mustard-plasters  or  mustard 
foot-baths,  or  the  application  of  the  faradic  current,  also  produces 
good  results.  Too  much  attention  must  not  be  paid  to  the 
patient,  and  the  nurse  must  assume  a  strictly  impersonal  atti- 
tude and  avoid  all  expressions  of  sympathy. 

The  after-treatment  of  the  individual  who  has  had  a  hysteric 
attack  or  who  exhibits  hysteric  symptoms  is  just  as  important 
as  the  prophylactic  treatment  in  the  child. 

It  has  been  my  experience  that  a  large  percentage  of  persons 
with  a  hysteric  temperament,  if  properly  treated,  can  be  educated 
to  exert  emotional  self-control,  self-denial,  and  to  acquire  a 
spirit  of  contentment  in  their  accustomed  surroundings.  In 
the  large  percentage  it  is  advisable,  and  sometimes  absolutely 
necessary,  to  remove  them  from  their  usual  surroundings,  and 
place  them  in  a  hospital  or  in  some  place  where  they  will  come 
in  contact  only  with  strangers.  Here  the  physician  will  have 
complete  control  of  the  patient,  and  he  will  meet  individuals 
who  will  set  him  a  good  example  in  the  exercise  of  self-control. 
In  the  severer  cases  absolute  isolation,  excepting  only  physician 
and  nurse,  is  necessary. 

With  the  patient  under  these  conditions,  it  is  first  necessary 
to  correct  any  existing  physical  ailments.  The  diet  should  be 
regulated,  and  the  patient's  general  physical  condition  brought 
to  the  normal.  His  powers  of  resistance  are  to  be  increased  by 
the  giving  of  cold  and  hot  sponges,  and  his  strength  is  to  be  aug- 
mented by  proper  exercise.  The  bowels  are  to  be  regulated  by 
the  administration  of  laxatives  and  by  the  promotion  of  regular 
habits.  Any  symptoms  that  may  occur  are  to  be  met  either  by 
frank  explanation  and  suggestion  or  by  the  use  of  medicine  or 
physical  means,  accompanied  by  proper  suggestion. 

During  the  entire  time  that  the  patient  is  under  treatment  the 
intellectual  intercourse  between  physician  and  patient  must 
be  of  a  stimulating,  cheering  nature.  The  patient  is  to  be 
constantly  reassured  and  encouraged,  and  every  effort  should 
be  made  to  establish  in  the  patient  a  determination  to  over- 
come his  disability  and  to  exercise  control  over  his  emotions — to 


NEURASTHENIA,    OR    NERVOUS    EXHAUSTION  493 

become,  as  far  as  possible,  master  of  himself.  He  should  be 
warned  that  failures  and  relapses  are  to  be  expected,  but  that 
with  determination  and  constant  struggle  on  his  part  he  will 
eventually  win  the  battle  and  become  master  of  the  situation.. 
The  future  of  these  patients  must  be  carefully  directed  for  a 
considerable  length  of  time.  They  should  be  encouraged  to 
meet  excitement  with  indifference,  and  to  avoid,  so  far  as  pos- 
sible, emotional  disturbances  and  distressing  incidents;  to  live 
a  regular  life,  and  to  avoid  mental  and  physical  excesses.  They 
should  not  give  undue  attention  to  minor  physical  ailments, 
but  rather  than  remain  anxious  and  uncertain  it  is  advisable 
for  them  to  consult  a  physician  to  discover  the  true  nature  of 
such  ailments. 

In  the  treatment  of  these  patients  it  is  of  inestimable  value 
to  discover  the  cause  of  the  symptoms. 

Many  patients,  particularly  if  they  have  confidence  in  their 
physician,  will,  after  careful  inquiry,  frankly  unburden  their 
minds  and  acknowledge  the  cause  of  the  attack ;  there  are,  how- 
ever, some  few  cases  who  either  do  not  know  the  cause  of  their 
condition  or  are  firmly  convinced  that  no  emotional  disturbance 
has  produced  it;  such  patients  find  it  practically  impossible 
to  unburden  themselves,  and  consequently  the  unpleasant  ex- 
periences are  repressed  into  the  subconscious  mind  and  act  as 
psychic  irritants;  such  irritating  processes  must  be  dispelled  or 
they  become  converted  into  physical  manifestations  and  evidence 
themselves  in  hysteric  symptoms  and  attacks.  It  is  in  this 
very  limited  class  of  individuals  that  much  is  to  be  expected  from 
a  psycho-analysis  (performed  by  a  properly  trained  physician) 
that  tends  to  discover  and  to  bring  to  light  those  psychic  irri- 
tants. It  is  by  freeing  the  mind  of  irritating  experiences  that 
one  may  relieve  the  patient's  symptoms. 

NEURASTHENIA,   OR  NERVOUS   EXHAUSTION 

Neurasthenia  is  a  very  common  disease,  occurring  more 
frequently  in  individuals  who  live  in  large  centers  of  population. 
Attention  was  first  prominently  called  to  this  disease  in  1869 
by  an  American  physician  named  Beard,  who  applied  the  name 


494  MANUAL   OF   NERVOUS   DISEASES 

neurasthenia  to  a  state  of  chronic  nervous  fatigue  and  to  the 
symptoms  that  were  caused  as  the  result  of  a  chronic  patho- 
logic exhaustion  of  the  nervous  system.  The  disease  had, 
of  course,  existed,  been  recognized,  and  described  before  this 
time.  It  would  appear  that  under  the  stress  and  strain  of 
modern  civilization  this  disease  is  occurring  with  much  greater 
frequency  than  formely. 

Etiology. — Heredity  is  the  most  important  predisposing  factor. 
In  many  cases  careful  inquiry  into  the  family  history  shows  the 
presence  of  mild  hereditary  taints — of  debilitating  or  toxic 
conditions  in  the  parents  preceding  the  conception  and  birth 
of  the  affected  individual.  In  the  type  of  neurasthenia  that 
develops  in  young  children  and  young  adults  after  very  minor 
exciting  causes  (neurasthenia  praecox)  there  is  generally  a  history 
of  marked  neuropathic  taint  in  the  ancestry.  These  individuals 
are  born  with  a  deficient  stamina  and  weakened  reserve  force 
of  the  nervous  system,  which,  with  or  without  exciting  cause, 
becomes  easily  fatigued,  and  regains  a  normal  state  only  with 
difficulty,  if  at  all. 

Sex. — It  occurs  in  both  males  and  females,  but  with  greater 
frequency  in  males. 

Age, — ^The  disease  manifests  itself  most  frequently  between 
the  twentieth  and  the  fiftieth  year — at  the  time  of  life  when  the 
individual  is  putting  forth  his  greatest  efforts,  often  under 
unfavorable  conditions,  to  attain  success.  The  disease  may 
occur  at  any  period,  neurasthenia  praecox  appearing  sometimes 
in  the  very  earliest  years  of  life.  It  may  also  appear  after  the 
fiftieth  year. 

Occupations  that  involve  confinement,  close  attention  to 
detail,  anxiety,  great  concentration,  responsibility,  etc.,  pre- 
dispose to  this  condition. 

Neurasthenia  occurs  more  frequently  in  persons  of  an  ex- 
citable and  emotional  temperament  than  in  those  of  a  phlegmatic 
disposition.  Any  disease  or  condition  that  lowers  the  general 
health  predisposes  to  nervous  exhaustion.  Under  unfavorable 
conditions  neursathenia  may  develop  after  any  of  the  infectious 
diseases,  particularly  after  influenza,  following  severe  hem- 
orrhages, diseases  of  the  genital  organs,  eyes,  nose,  or  throat. 


NEURASTHENIA,    OR   NERVOUS    EXHAUSTION  495 

It  may  occur  in  the  wake  of  prolonged  intoxications,  whether  of 
endogenous  or  exogenous  origin.  Syphilitic  infection,  by  bring- 
ing about  a  decreased  physical  resistance,  and  owing  to  the  fact 
that  it  is  usually  accompanied  by  marked  emotional  disturbance 
of  a  depressive  nature,  may  be  an  etiologic  factor,  as  may  also 
uncongenial  employment,  sudden  changes  in  one's  habits, 
overwork,  sexual  excesses,  and  the  like. 

Overwork  with  insufficient  rest,  anxiety,  worry,  and  trauma, 
in  the  presence  of  any  of  the  predisposing  factors,  are  the  most 
frequent  exciting  causes  of  the  disease. 

The  commonest  and  most  important  cause  of  neurasthenia  is 
mental  or  physical  overwork,  with  insufficient  rest,  carried  on  in 
an  atmosphere  of  anxiety  and  worry.  It  is  seen  oftenest  in 
individuals  whose  general  health  has  become  debilitated  by 
injudicious  or  unhygienic  living,  or  as  the  result  of  disease  or 
intoxication,  and  in  whom  there  may  or  may  not  be  a  tainted 
hereditary  history. 

Pathology. — ^A  careful  examination  of  the  nervous  system 
fails  to  reveal  any  organic  changes.  A  consideration  of  tJie  symp- 
toms, course  of  the  disease,  and  the  results  obtained  by  treat- 
ment, taken  together  with  the  examination  of  the  central  ner- 
vous system,  leads  one  to  the  conclusion  that  in  neurasthenia 
there  exists  a  state  of  fatigue  or  exhaustion  of  the  cells  of  the 
central  nervous  system;  that  these  cells  do  not  regain  their 
normal  state  after  the  usual  amount  of  rest,  but  that  in  many 
cases  a  comparatively  normal  state  may  be  reestablished  as  the 
result  of  prolonged  rest  combined  with  proper  attention  to  nutri- 
tion. 

If  this  conception  of  neurasthenia  is  true,  the  neurasthenic 
state  differs  only  in  degree  from  the  fatigue  which  every  one 
experiences  as  the  result  of  overw^ork;  consequently  the  amount 
of  rest  required  in  the  neurasthenic  state  must  greatly  exceed 
the  amount  that  w^ould  relieve  normal  fatigue.  The  mental 
state  of  the  individual  suffering  from  neurasthenia  is  also  very 
important — these  individuals  are  usually  depressed,  intro- 
spective, anxious,  and  apprehensive;  mental  rest  is,  therefore, 
very 'difficult  to  attain.  As  the  unconscious  mental  activity  is 
just  as  exhausting  as,  if  not  more  so  than,  conscious  and  phys- 


496  MANUAL  OF  NERVOUS  DISEASES 

ical  unrest,  a  vicious  circle  is  established  whereby  the  nervous 
system  is  maintained  in  a  state  of  exhaustion.  It  is  the  presence 
of  this  vicious  circle  that  renders  the  establishment  of  a  state 
of  complete  rest  so  difficult,  and  consequently  makes  the  cure 
of  this  condition  doubtful  and  sometimes  impossible. 

The  mental  state  is  caused  by  difficulty  in  the  complex  inter- 
associative  activities  of  the  higher  cerebral  centers.  This 
difficulty  in  association  and  in  interactivity  is  caused  by  the 
exhausted  state  of  the  nerve-cells.  The  mental  condition  is 
usually  associated  wirh  emotional  disturbances,  and  these  in 
turn  cause  or  are  accompanied  by  abnormalities  in  the  functions 
of  the  sympathetic  system.  These  latter  bring  about  abnormal 
states  in  the  vasomotor  system,  the  secretions,  and  the  somatic 
sensibilities;  sensations  depending  upon  abnormal  functioning 
of  these  structures  are  reflected  upon  consciousness,  and  in  turn 
give  rise  to  fear,  anxiety,  uncertainty,  etc.,  thus  tending  to 
intensify  the  emotional  state. 

As  a  further  result  of  the  fatigue  or  exhausted  state  of  the 
cerebral  cells  their  power  becomes  diminished,  and  voluntary 
efforts  are  put  forth  only  with  difficulty.  There  is  a  feeling  of 
deficiency,  incompetency,  and  weakness,  and  as  a  result  of 
these  feelings  impatience  and  irritability  manifest  themselves. 

In  many  persons  in  whom  there  is  a  marked  predisposition 
to  the  development  of  a  neurasthenic  state  physical  peculiar- 
ities are  present,  the  most  common  of  which  are  scoliosis,  gastrop- 
tosis,  enteroptosis,  visceroptosis,  floating  kidney,  flat,  narrow 
chest,  disturbances  of  vision  and  refractive  errors,  absence  of 
muscle  tone,  etc. 

Symptoms. — The  symptoms  of  neurasthenia  are  practically 
innumerable.  Every  function  of  the  body  may  become  dis- 
turbed, and  either  be  reflected  upon  consciousness,  giving  rise  to 
discomfort,  or  manifest  itself  in  some  variation  from  the  normal. 

A  careful  examination  of  these  disturbances  of  function  will 
reveal  the  fact  that  while  a  deficiency  is  present,  there  is  never 
a  complete  loss  of  the  functions.  Added  to  the  deficiency  there 
is  usually  an  increased  reaction  to  stimuli,  generally  of  a  dis- 
agreeable nature. 

All  the  symptoms  of  neurasthenia  are  due  to  a  state  of  fatigue 


NEURASTHENIA,    OR   NERVOUS    EXHAUSTION  497 

involving  the  various  structures  of  the  body;  consequently, 
when  voluntary  effort  is  made  to  use  these  various  structures, 
the  response  is  brought  forth  only  with  effort,  and  the  resulting 
activity  is  usually  incomplete  and  occasions  dissatisfaction  in 
the  mind  of  the  individual,  who  feels  his  incapacity  and  inability 
to  produce  the  desired  results,  and  therefore  becomes  impatient, 
apprehensive,  and  irritable.  Being  in  a  state  of  fatigue  and 
irritability,  the  patient  becomes  hypersensitive  to  many  forms 
of  stimulation,  and  the  fatigue  occasions  discomfort  which  mani- 
fests itself  in  the  form  of  pain. 

Owing  to  the  fatigue  and  irritable  state  of  the  mind,  emotional 
disturbances  have  an  increased  influence  on  the  mental  activi- 
ties, and  are  also  frequently  reflected,  in  an  exaggerated  manner, 
upon  the  physical  functions  of  the  body. 

In  neurasthenia  a  rapid  fatigue  manifests  itself  in  the  disturbed 
activity  of  practically  all  the  functions  of  the  body.  In  many 
cases  disturbed  activity  of  some  organ  or  system  of  the  body 
stands  out  prominently  in  the  disease  picture. 

A  predisposition  to  local  symptoms  is  due  either  to  a  congenital 
weakness  or  to  an  exhausted  state  of  an  organ  or  system  of  the 
body  as  the  result  of  overwork  or  of  impaired  general  health 
by  disease,  combined  with  overwork  of  that  portion  of  the 
body. 

The  mental  state  in  this  disease  is  one  marked  more  or  less 
by  apprehension.  The  patient  is  irritable  and  introspective, 
and  mental  activity  occasions  a  sense  of  discomfort.  The 
individual  complains  of  inability  to  fix  his  attention  for  any 
length  of  time  upon  any  one  line  of  thought,  and  there  is  a 
tendency  for  his  thoughts  to  wander ;  he  also  complains  of  weak- 
ness of  memory  which,  in  fact,  does  not  exist.  This  apparent 
weakness  of  memory  is  due  to  the  inability  of  the  patient  to 
concentrate  his  attention  upon  one  line  of  thought,  and  conse- 
quently the  impressions  are  very  superficial  and  soon  disappear. 
This  defect  of  memory  applies  only  to  unimportant  happen- 
ings— events  or  matters  of  importance  are  well  retained.  There 
is  inability  to  concentrate  thought  and  to  accomplish  w^ork  that 
requires  prolonged  mental  application.  The  patient  can  come 
to  no  conclusion,  indecision  being  a  prominent  symptom. 
32 


498  MANUAL   OF   NERVOUS   DISEASES 

Mental  activity  lacks  vigor  and  is  somewhat  retarded;  con- 
sequently these  individuals  complain  of  difficulty  or  inability 
to  think.  The  intellectual  powers  are  never  greatly  impaired. 
Fatigue  prevents  long-sustained  mental  application. 

The  emotional  tone  in  these  individuals  is  generally  one  of 
depression.  Thus  they  weep,  either  openly  or  with  some 
attempt  at  repression,  when  relating  their  symptoms  or  when 
contemplating  their  future.  As  a  result  of  physical  and  mental 
weakness  a  sense  of  fear  develops.  Such  persons,  being  intro- 
spective, misconstrue  their  symptoms  and  develop  various 
phobias;  these  are  always  associated  with  a  sense  of  discomfort 
or  incapacity  in  some  organ  or  system  of  the  body;  at  times  these 
fears  become  associated  with  some  external  condition,  and  may 
recur  whenever  the  individual  finds  himself  in  a  similar  situa- 
tion. 

Among  the  commoner  forms  of  fear  is  that  of  insanity — 
the  patient  notices  that  he  has  difficulty  in  remembering  and 
in  fixing  his  attention,  and  that  there  is  inability  to  concentrate 
the  thoughts,  and  that  these  symptoms  are  the  forerunners  of  a 
mental  breakdown.  When  he  has  attacks  of  palpitation,  short- 
ness of  breath,  or  pain  in  the  chest,  he  fears  heart  trouble  or 
pulmonary  disease;  pain  in  the  back  makes  him  apprehensive 
of  kidney  or  spinal  trouble;  weakness  and  pain  in  the  legs  make 
him  fear  locomotor  ataxia,  etc.  Sometimes  attacks  of  palpita- 
tion occur  in  crowded  places  or  while  the  patient  is  alone  or 
under  some  unusual  condition,  and  subsequently  he  fears  to 
place  himself  in  a  similar  situation  for  fear  of  a  recurrence  of 
the  symptoms. 

The  neurasthenic  can  always  be  reasoned  with  and  be  made 
to  realize  that  his  fears  are  groundless,  although  he  may  not 
always  be  able  to  dispel  them. 

Disturbance  of  sleep  is  a  very  common  occurrence  in  neuras- 
thenia. Many  patients  complain  of  inability  to  sleep,  con- 
tending that  they  sleep  for  only  a  few  minutes  during  the  entire 
twenty-four  hours;  others  have  great  difficulty  in  going  to  sleep 
and  awaken  early;  some  fall  asleep  soon  after  retiring,  but  awaken 
after  a  few  hours  and  are  unable  to  go  to  sleep  again;  in  some 
the  sleep  is  very  light;  marked  restlessness  occurs,  and  they 


NEURASTHENIA,    OR   NERVOUS   EXHAUSTION  499 

awaken  upon  the  slightest  noise;  not  infrequently  they  awake 
in  a  state  of  terror.  Again  the  sleep  is  light  and  restless,  and 
is  disturbed  by  terrifying  dreams;  in  practically  all  cases  the 
sleep  is  unrefreshing,  and  the  individual  awakens  feeUng  more 
tired  than  he  was  upon  retiring. 

Sensory  Symptoms. — There  is  often  complaint  of  a  general 
tired  feeling — that  various  portions  of  the  body  feel  heavy; 
or  of  an  unnatural  or  light  feeling  of  some  portion  or  of  the  entire 
body;  or  numbness,  tingling,  or  burning  may  be  complained  of; 
that  sensation  is  not  acutely  perceived,  or  that  there  is  a  slow- 
ness in  its  perception.     Loss  of  sensation  is  not  present. 

Pain  is  also  very  frequently  complained  of.  It  may  be  diffuse 
or  limited  to  some  part  or  organ  of  the  body,  and  is  usually 
accentuated  upon  physical  exertion  or  upon  excitement.  Head- 
ache and  peculiar  sensations  about  the  head  are  common  symp- 
toms. The  headache  may  be  slight  or  severe  and  may  be  con- 
stant or  occur  only  upon  physical  or  mental  exertion  or  as  the 
result  of  emotional  disturbances.  It  may  be  diffuse,  or  may 
involve  principally  the  frontal  region,  the  vertex  of  the  head,  or 
the  occipital  region;  in  the  latter  case  the  patient  generally 
declares  he  has  a  pain  at  the  base  of  the  brain.  The  pain  may  be 
described  as  passing  through  the  head  from  the  back  of  the  eyes 
into  the  occipital  region;  sometimes  it  is  described  as  a  pressure 
within  the  head,  as  if  the  skull  were  too  small  for  the  brain. 
Frequently  there  is  a  sense  of  constriction  about  the  head,  and 
at  other  times  there  is  a  feeling  as  if  a  weight  were  pressing  on 
the  top  of  the  head.  Backache  is  also  frequently  complained  of, 
and  there  is  a  sense  of  weakness,  dragging,  pressure,  and  tender- 
ness along  the  course  of  the  spine.  The  tenderness  along  the 
spine  is  usually  of  a  rather  superficial  character,  and  is  relieved 
by  deep  pressure.  The  spine  is  generally  more  tender  over 
its  prominent  parts  and  in  the  region  of  the  coccyx ;  in  this  latter 
situation  tenderness  and  pain  are  sometimes  so  intense  as  to 
interfere  with  sitting.  Complaint  is  also  made  of  many  other 
disturbances  of  sensation,  such  as  stiffness,  soreness,  a  sense  of 
heat  or  cold,  etc.,  which  may  be  referred  to  all  or  to  any  part  of 
the  body. 

Many  neurasthenics  are  hypersensitive  to  heat  or  cold,  ex- 


500  MANUAL   OF   NERVOUS   DISEASES 

posure  to  slight  increases  in  temperature  giving  rise  to  great 
discomfort. 

Symptoms  Pointing  to  Involvement  of  the  Special  Senses. — ^The 
visual  centers  may  be  either  in  a  state  of  irritation,  evidenced 
by  the  patient  seeing  spots,  bright  points,  patches,  etc.,  more 
or  less  constantly  before  the  eyes,  or  there  may  be  rapid  fatigue 
of  these  centers,  the  individual  complaining  of  inability  to  read 
for  any  length  of  time,  the  letters  becoming  after  a  short  period 
indistinct,  running  into  one  another,  and  sometimes  everything 
seems  to  be  clouded  and  indistinct.  If  the  eyes  are  used  for 
any  length  of  time  there  occur  marked  cephalic  discomfort  and 
a  drawing  sensation  in  the  back  of  the  head.  The  hearing  may 
also  become  involved;  thus  the  individual  becomes  sensitive  to 
noises,  complains  of  peculiar  sounds  in  the  ears,  such  as  ringing 
blowing,  whistling,  etc.;  in  some  cases  both  hearing  and  seeing 
are  accompanied  by  discomfort,  an  apparent  hypersensitiveness 
being  present.  In  a  few  cases  the  sense  of  taste  and  of  smell 
also  become  affected,  the  patient  becoming  either  hypersensitive 
or  complaining  of  a  decreased  acuteness  of  these  sensations. 
The  pupils  are  usually  very  mobile,  and  are  frequently  widely 
dilated. 

Careful  examination  fails  to  reveal  any  organic  basis  for 
these  complaints. 

Vertigo. — There  is  a  sense  of  uncertainty  and  giddiness,  and 
the  patient  experiences  a  feeling  as  if  he  were  going  to  fall. 
These  attacks  are  usually  accompanied  by  a  marked  state  of 
fear,  and  in  some  instances  may  so  far  influence  the  individual 
as  to  prevent  him  from  going  out  alone. 

Symptoms  Due  to  Disturbed  Activity  of  the  Motor  Functions. — 
Frequently  there  is  complaint  of  weakness  and  of  rapid  fatigue, 
but  practically  never  of  paralysis.  There  is  a  lack  of  strength, 
and  movements  are  carried  out  slowly.  Labor  requiring 
physical  effort  is  accomplished  only  with  difhculty.  Owing  to 
the  sense  of  weakness  and  rapid  fatigue,  patients  fear  that  the 
weakness  will  develop  into  a  paralysis. 

Tremor. — Along  with  the  sense  of  weakness  and  rapid  fatigue 
there  is  often  tremor  of  a  rapid,  fine,  vibratory  nature.  Fre- 
quently this  occurs  only  during  voluntary  movements  and  after 


NEURASTHENIA,    OR   NERVOUS   EXHAUSTION  501 

excitement,  disappearing  entirely  while  the  individual  is  at  rest. 
A  fine  fibrillary  tremor  affecting  the  orbicularis  palpebrarum 
and  the  orbicularis  oris  muscles  frequently  occurs  during  emo- 
tional disturbances. 

The  tendon  reflexes  and  the  mechanical  excitability  of  mus- 
cles and  nerves  are  usually  exaggerated.  The  muscle  tone 
and  volume  remain  normal,  except  in  those  cases  in  which 
there  is  much  general  emaciation,  when  the  muscles  may  become 
flabby  and  the  tendon  reflexes  be  elicited  only  with  difficulty. 
Loss  of  a  tendon  reflex  never  occurs  in  neurasthenia.  Such  loss 
always  indicates  the  existence  of  an  organic  disease. 

Cardiac  Symptoms. — ^Attacks  of  cardiac  palpitation  ac- 
companied by  precordial  distress  are  of  frequent  occurrence. 
Such  attacks  may  come  on  after  physical  exertion  or  excitement, 
or  may  occur  without  apparent  cause.  Attacks  simulating 
angina  pectoris,  in  which  there  are  diffuse  pain  in  the  chest  and 
arms,  rapid  pulse,  and  marked  anxiety,  also  occur.  Complaint 
is  frequently  made  of  the  consciousness  of  the  heart's  action, 
the  individual  feeling  as  if  the  heart  were  about  to  cease 
beating. 

In  neurasthenia  the  pulse-rate  usually  ranges  from  90  to 
120,  acceleration  occurring  upon  physical  effort  or  as  the  effect 
of  emotional  disturbances.  Frequently  the  taking  of  food  or 
the  use  of  coffee  or  tobacco,  as  well  as  sexual  excitement, 
emotional  disturbances,  etc.,  will  markedly  increase  the  pulse- 
rate.  In  some  cases  pressure  over  a  painful  point  accelerates 
the  pulse-rate  10  or  20  beats  a  minute;  this  is  known  as  Rumpf's 
sign.     The  blood-pressure  in  neurasthenia  is  usually  low. 

Vasomotor  disturbances  are  present  in  a  large  number  of 
cases,  and  consist  of  a  feeling  as  of  a  rush  of  blood  to  the  head, 
which  may  be  associated  with  pulsation  and  peculiar  sensations 
in  or  under  the  scalp ;  flushing  of  the  skin,  which  may  be  localized 
or  diffuse,  and  which  generally  is  objectively  evident,  etc.  The 
temperature  of  the  skin  in  the  flushed  areas  is  usually  slightly 
elevated,  and  slight  irritation  of  the  skin  may  cause  severe  and 
persistent  redness,  resulting  in  dermographia,  urticaria,  etc. 

There  may  be  rapid  alterations  of  vascular  tone — sometimes 
there  is  a  more  or  less  persistent  venous  congestion,  the  face 


502  MANUAL  OF  NERVOUS  DISEASES 

being  flushed,  and  the  Hps  taking  on  a  bluish  hue.  The  ex- 
tremities are  cold,  moist,  somewhat  swollen,  and  cyanotic  in 
appearance. 

In  women  disturbances  of  menstruation  are  common;  thus 
the  period  may  become  too  frequent,  the  flow  be  excessive,  or 
the  interval  prolonged  and  the  flow  scanty.  An  exaggeration 
of  many  of  the  nervous  symptoms  usually  occurs  at  the  menstrual 
period. 

A  very  common  symptom,  is  that  of  consciousness  of  the 
throbbing  of  the  aorta,  and  pressure  over  this  vessel  usually 
causes  considerable  pain. 

Disturbance  of.  Secretion. — ^There  may  be  marked  increase  of 
perspiration,  the  entire  body  being  moist;  in  some  cases  the  hands 
and  feet  are  constantly  moist.  The  flow  of  saliva  and  of  urine 
may  be  greatly  increased.  The  secretions  of  the  stomach, 
intestines,  joints,  etc.,  may  be  increased  or  decreased,  and 
their  composition  may  be  altered.  These  changes  may  vary 
from  time  to  time. 

Symptoms  Referable  to  Disturbed  Activity  of  the  Genito-urinary 
Apparatus. — In  many  instances  there  may  be  physical  derange- 
ment of  the  sexual  apparatus.  This  may  be  of  prolonged 
duration,  and  when  symptoms  pointing  to  the  genital  organs 
are  present,  an  organic  condition  should  be  carefully  sought 
for.  Early  or  excessive  masturbation  may  be  the  causative 
factor  of  a  neurasthenic  state,  or  it  may  in  itself  be  a  symptom 
of  a  neuropathic  disposition.  At  first  masturbation  is  indulged 
in  for  the  physical  sensation  induced,  the  sensation  resulting 
from  the  local  physical  stimulation  being  sufficient  to  produce 
the  desired  result.  Later  mental  imagery  is  called  upon  to 
assist  the  local  physical  sensation.  The  mind,  being  more  or 
less  constantly  occupied  with  sexual  thoughts,  or  as  the  result 
of  excessive  sexual  indulgences,  the  genital  centers  remain  in  a 
state  of  abnormal  activity,  and  there  results  an  excessive  secre- 
tion of  the  sexual  glands.  As  a  consequence  erections  occur 
readily,  and  emissions  are  frequent;  finally  erections  become 
imperfect,  premature  ejaculations  occur,  and  the  patient  ob- 
serves that  there  is  a  loss  of  semen  after  urination  or  defecation. 
In  these  cases  ejaculation  is  not  accompanied  by  erection  or 


NEURASTHENIA,    OR   NERVOUS    EXHAUSTION  503 

pleasurable  sensation.  As  the  result  of  these  symptoms  the 
patient  becomes  alarmed,  depressed,  and  fearful  of  the  occur- 
rence of  spinal  cord  diseases  and  of  impotence. 

In  some  cases,  even  without  masturbation  or  ex:cessive  sexual 
indulgence,  there  is  a  gradual  decrease  of  the  sexual  appetite 
and  of  sexual  ability.  Under  these  conditions  the  patient  be- 
comes depressed  and  alarmed,  fearing  total  sexual  incapacity. 
This  fear  of  becoming  impotent  may  interfere  with  erection 
and  psychic  impotence  may  result,  which  in  turn  may  be  fol- 
lowed by  many  neurasthenic  symptoms.  Sensory  disorders, 
such  as  numbness,  coldness,  pain,  sensitiveness,  etc.,  may 
affect  the  genital  organs.  A  mental  state  of  fear,  combined  with 
depression,  is  most  marked  in  these  individuals. 

The  functions  of  the  bladder  are  often  markedly  affected  in 
neurasthenia.  Owing  to  the  concentrated  and  disturbed  com- 
position of  the  urine  there  may  be  irritation  of  the  bladder, 
with  frequent  micturition.  In  other  cases  in  which  there  is  no 
local  disturbance  of  the  bladder  frequent  micturition  may  also 
be  present. 

The  urine  may  be  decreased  in  amount  and  highly  colored, 
or  there  may  be  a  marked  increase  in  the  quantity  secreted; 
in  either  case  there  may  be  an  increased  frequency  of  urination. 
As  a  rule,  the  urine  contains  an  increased  amount  of  phos- 
phates and  oxalates. 

Symptoms  pointing  to  disturbance  of  the  functions  of  the  gastro- 
intestinal tract  occur  very  frequently  in  this  disease.  Loss  of 
appetite  and  peculiar  sensations  are  complained  of.  The  latter 
consist  of  a  feeling  of  emptiness  or  of  fulness;  a  sensation  of 
constant  hunger,  which  is  not  relieved  by  food;  a  quivering, 
trembling,  or  throbbing  sensation  referred  to  the  stomach;  pain 
on  pressure  over  the  abdomen;  eructation;  vomiting;  meteorism, 
etc.  All  or  any  combination  of  these  symptoms  may  be  present. 
In  many  instances  the  individual  complains  of  digestive  dis- 
turbances, asserting  that  he  is  unable  to  digest  acid  fruits, 
meats,  milk,  etc.  Many  patients  adhere  to  a  very  rigid  diet, 
believing  their  condition  to  be  due  primarily  to  a  gastric  disease. 
Some  individuals  have  so  restricted  their  diet  that  they  practi- 
cally live  on  crackers  and  water.    In  some  cases  the  patient 


504  MANUAL   OF  NERVOUS  DISEASES 

complains  of  distress  immediately  after  eating;  in  others  the 
gastric  symptoms  do  not  occur  for  an  hour  or  more  after  taking 
food.  The  gastric  symptoms  are  frequently  accompanied  by  a 
sense  of  heaviness  and  of  oppression,  with  palpitation,  general 
weakness,  and  in  some  cases  considerable  abdominal  pain. 
These  symptoms  usually  become  intensified  after  physical 
exertion,  anxiety,  or  emotional  disturbances.  An  examination 
of  the  gastric  secretion  shows  no  constant  deviations — in  some 
instances  there  is  a  hyperacidity;  in  others  there  is  a  hypo- 
acidity or  an  anacidity,  and  in  many  there  are  variations  of 
the  secretion  from  time  to  time. 

Constipation,  peculiar  feelings,  and  distress  in  the  intestines 
are  also  frequently  complained  of.  Attacks  of  diarrhea  caus- 
ing great  weakness  may  occur;  such  attacks  sometimes  occur 
only  in  the  morning,  whereas  others  follow  excitement  and 
emotional  disturbances.  In  one  form  of  persistent  diarrhea 
there  is  considerable  pain,  and  a  large  amount  of  mucus  in 
stringy  masses  is  passed;  in  these  attacks  there  is  great  exhaus- 
tion, and  the  patient  regards  these  frequent  stools  containing 
this  stringy  mucus  with  great  apprehension.  The  pain  is  very 
severe,  and  the  attacks  are  dreaded.  This  condition  is  de- 
scribed as  mucous  colitis,  and  may  persist  for  many  years. 
The  attacks  are  always  increased  by  physical  exertion,  excite- 
ment, and  emotional  disturbances. 

The  gastro-intestinal  disturbances  cause  considerable  dis- 
comfort, and  arouse  in  the  patient's  mind  a  fear  of  a  serious 
disease  of  the  gastro-intestinal  tract.  As  these  symptoms  are 
associated  with  the  taking  of  food,  or  are  the  result  of  the  loss 
of  appetite,  the  individual  gradually  restricts  his  diet  or  dimin- 
ishes the  amount  of  food  taken,  and  as  a  consequence  it  is  not 
unusual  for  loss  of  weight  and  strength  and  unhealthy  condi- 
tions of  the  skin  to  occur.  In  many  persons  gastroptosis  and 
enteroptosis  occur  as  a  congenital  condition,  or  are  the  result 
of  absorption  of  the  mesenteric  fat. 

Trophic  Disorders. — ^Trophic  disorders  are  not  common,  but 
premature  graying  of  the  hair  frequently  occurs.  The  general 
state  of  nutrition  may  or  may  not  be  disturbed.  In  many 
cases  in  which  there  are  much  loss  of  sleep,  restlessness,  gastro- 


NEURASTHENIA,    OR   NERVOUS    EXHAUSTION  505 

intestinal  symptoms,  and  the  like  there  is  marked  loss  of 
weight  and  strength. 

Course  of  the  Disease. — In  the  vast  majority  of  cases  neuras- 
thenia develops  very  slowly,  new  symptoms  appearing  from 
time  to  time.  The  disease  may  manifest  itself  in  early  child- 
hood, such  children  always  presenting  a  marked  congenital 
predisposition.  This  predisposition  is  manifested  either  by  the 
history  of  neuropathic  taint  in  the  ancestry  or  by  physical 
impairment  of  the  health  of  the  parents  preceding  conception, 
or  by  nervous  debility  of  the  mother  during  the  time  she  was 
carrying  the  child.  These  children  are  usually  nervous,  and 
when  overstimulated,  either  mentally  or  physically,  complain 
of  many  neurasthenic  symptoms.  In  older  children  or  adults 
who  are  working  under  unfavorable  mental  or  physical  condi- 
tions a  neurasthenic  state  may  develop  as  the  result  of  trauma, 
emotional  shock,  or  acute  illness.  More  often  s}TQptoms  de- 
velop after  physical  or  mental  overexertion,  particularly  if  com- 
bined with  w^orry  or  if  conjoined  with  unfavorable  physical  sur- 
roundings. The  symptoms  may  be  so  mild  at  first  that  the 
individual  does  not  heed  the  w^aming,  or  attributes  them  to 
a  local  physical  condition,  and  hence  does  not  apply  the  proper 
remedy.  The  symptoms  gradually  become  more  marked,  the 
mental  anxiety  increases,  the  capacity  for  work  diminishes,  and, 
as  a  consequence,  a  vicious  circle  is  established  in  which  worry, 
introspection,  anxiety,  and  decreased  capacity  for  w^ork  are 
present,  wdth  increased  demands,  owing  to  the  fact  that  the 
work  is  never  completed. 

If  untreated  and  if  the  causative  factors  are  not  removed 
neurasthenia  displays  a  tendency  to  grow  gradually  w^orse, 
and  may  last  many  years.  Rarely  are  all  the  s>Tnptoms  of  this 
disease  present,  but  usually  some  group  of  symptoms  stands 
out  prominently,  which  has  led  some  authorities  to  describe  the 
disease  under  the  heads  of  the  different  t}^es,  for  example: 
Gastro-intestinal,  spinal,  vasomotor,  sexual  types,  etc. 

Neurasthenia  does  not  run  a  regular  course.  The  course 
of  the  disease  is  marked  by  periods  of  improvement  and  ex- 
acerbations of  symptoms;  for  example,  there  may  be  periods 
during  which  the  patient  feels  comparatively  well,  and  these 


5o6  MANUAL  OF  NERVOUS  DISEASES 

may  alternate  with  periods  of  marked  increase  of  symptoms. 
As  a  rule,  the  individual  feels  worse  early  in  the  day. 

Prognosis. — Neurasthenia  developing  in  early  childhood,  if 
promptly  and  properly  treated,  recovery  is  to  be  expected. 
As,  however,  these  children  are  usually  reared  in  an  unfavor- 
able atmosphere  and  are  inherently  weak,  relapses  are  prone 
to  occur.  In  some  cases,  particularly  in  those  developing 
very  early  in  childhood,  a  more  or  less  chronic  state  exists, 
and  the  patient  remains  an  invalid  during  his  entire  life.  In 
these  latter  cases  the  symptoms  change,  however,  from  time 
to  time;  thus  during  one  period  gastro-intestinal  symptoms 
may  be  prominent,  whereas  at  another  period  cerebral  symp- 
toms, spinal  symptoms,  or  sexual  symptoms  may  be  most 
marked. 

The  shorter  the  period  during  which  the  individual  has  been 
exposed  to  the  harmful  influences  of  overwork  and  worry,  and 
the  better  the  previous  health,  both  mental  and  physical,  the 
more  favorable  is  the  prognosis. 

The  vasomotor  and  sexual  symptoms  are  the  most  difficult 
to  eradicate.  The  prognosis,  as  a  rule,  for  recovery  from  an 
attack  is  fairly  good,  provided  the  cause  can  be  removed  and 
proper  treatment  instituted.  After  one  attack  has  occurred 
there  is  always  danger  of  another  if  the  patient  is  living  amid 
unfavorable  surroundings. 

Attacks  of  neurasthenia  occurring  after  an  acute  illness  the 
result  of  resuming  work  before  the  mental  and  physical  vigor  has 
been  reestablished,  if  properly  treated,  usually  present  a  good 
prognosis. 

The  cases  of  neurasthenia  in  which  phobias  are  among  the 
prominent  symptoms  are  usually  of  prolonged  duration  and 
very  resistant  to  treatment.  Neurasthenia  may  frequently 
be  combined  with  hysteria,  and  under  these  conditions  the 
disease  will  run  a  prolonged  course,  and  may  be  resistant  to 
treatment.  True  insanity  rarely  if  ever  develops  from  a  true 
neurasthenia. 

Traumatic  neurasthenia  presents  a  somewhat  unfavorable 
prognosis,  and  when  combined  with  the  anxiety  attendant  on 
law-suits,  may  tend  to  grow  worse.    Even  in  the  absence  of 


NEURASTHENIA,    OR   NERVOUS    EXHAUSTION 


507 


this  latter  factor  many  symptoms  may  persist  for  years  and 
prove  very  resistant  to  treatment. 

Diagnosis. — In  diagnosing  this  disease  it  is  very  important 
to  remember  that  there  are  many  organic  diseases  that  are 
ushered  in  with  neurasthenic  symptoms,  and  also  that  the  latter 
may  occur  during  the  course  of  an  organic  disease.  It  is, 
therefore,  most  important  to  make  a  careful  physical  examina- 
tion, bearing  in  mind  that  mental  fatigue,  difficulty  of  thought, 
etc.,  may  be  among  the  early  symptoms  of  a  general  paresis; 
that  malignant  growths,  general  arteriosclerosis,  nephritis, 
diseases  of  the  heart,  chronic  poisoning,  etc.,  may  all  give  rise 
to  neurasthenic  symptoms.  The  diagnosis  of  neurasthenia  is, 
therefore,  to  be  made  only  after  a  most  careful  physical  examina- 
tion, in  which  these  diseases  are  excluded.  The  history  of  the 
case  will  often  aid  the  diagnosis.  On  the  other  hand,  it  is  just 
as  important  not  to  treat  a  neurasthenic  individual  for  organic 
disease  merely  because  s)rmptoms  are  present  that  point  to 
disturbed  activity  of  some  organ  or  organs  of  the  body. 

Neurasthenia  is  differentiated  from  psychasthenia  by  the 
fact  that  in  the  latter  the  mental  symptoms  are  unduly  promi- 
nent, and  that  although  the  patient  realizes  the  absurdity  of  his 
feelings,  yet  he  is  unduly  influenced  by  them,  and  reacts  to 
them  with  marked  emotional  disturbance. 


Neurasthenia. 

In\'OLUTIONAL 

Melancholia. 

Depressed  State  of 

Manic-depressive 

Insanity. 

Age: 

History: 
Facial  expres- 

Childhood  or  early  adult 
life. 

Of  overwork  and  worry. 

Depressed  or  anxious. 

After  the  fortieth  year. 

Indefinite. 
Depressed  and  sad. 

First  attack  usually  be- 
tween the  fifteenth  and 
thirtieth  year. 

Of  previous  attack  of  ex- 
citement or  depression. 

Depressed  and  sad. 

Motor     func- 
tions : 
Judgment : 

Rapid  fatigue. 
Good. 

Usually  restless. 

Delusions  of  persecution 
and  of  a  somatic  na- 
ture. 

Psychomotor  retarda- 
tion. 

Delusions  in  which  self- 
accusation  or  seeming 
unworthiness  plays  a 
part. 

In  differentiating  neurasthenia  from  hypochondriasis  it  is 
.necessary  to  remember  that  in  the  latter  condition  the  in- 


5o8  MANUAL   OF   NERVOUS   DISEASES 

dividual's  idea  as  to  the  state  of  his  organs  and  as  to  the  cause  of 
his  symptoms  are  fixed,  and  usually  unreasonable  and  absolutely 
uninfluenced  by  argument.  Symptoms  pointing  to  mental  or 
physical  exhaustion  play  but  a  minor  part  in  the  picture  of 
hypochondriasis,  whereas  disturbance  of  somatic  sensations  are 
of  the  utmost  importance  in  diagnosing  this  disease.  For  ex- 
ample, when  the  patient  experiences  shortness  of  breath  or  has 
a  cough,  he  will  insist  that  his  lungs  are  entirely  destroyed;  or 
in  the  presence  of  very  minor  symptoms  he  will  assert  that  his 
kidneys  or  stomach  are  the  seat  of  incurable  disease,  and  he 
will  persist  in  his  belief  in  spite  of  reassurance  and  thorough 
examination  by  competent  physicians. 

Neurasthenia  must  also  be  differentiated  from  hysteria 
because  of  the  marked  difference  of  treatment  indicated  in 
these  two  diseases.  In  some  cases  a  neurasthenic  state  develops 
in  a  hysteric  individual.  For  the  differential  diagnosis  between 
these  two  diseases  see  Hysteria. 

The  importance  of  careful  history  taking  cannot  be  too 
strongly  impressed  upon  the  examiner,  and  in  making  the  phys- 
ical examination  every  effort  should  be  made  to  discover  the 
presence  of  mental  disease  or  of  organic  physical  disturbances. 
This  is  most  important,  so  that  the  patient  be  not  treated  for 
neurasthenia  when  an  organic  physical  disorder  or  a  mental 
disease  exists;  and,  conversely,  that  an  individual  be  not  treated 
for  a  physical  ailment  or  a  mental  affection  when  a  true  neuras- 
thenic state  is  present. 

Treatment. — ^To  prevent  the  development  of  neurasthenic 
states  in  children  or  in  individuals  who  are  of  a  nervous  tem- 
perament is  as  important  as  the  cure  of  the  condition  once 
it  has  set  in.  Children  who  are  of  a  nervous  temperament 
should  not  be  allowed  to  study  too  hard  at  school;  their  life 
should  be  so  ordered  that  they  will  spend  a  large  part  of  the 
time  out-of-doors  playing  and  exercising.  There  must  be  super- 
vision of  their  physical  efforts  in  order  to  avoid  undue  fatigue. 
They  should  sleep  in  well-ventilated  rooms,  be  given  non- 
stimulating  nutritious  food,  and  regularity  in  habits  as  re- 
gards playing,  working,  eating,  resting,  etc.,  should  be  culti- 
vated. 


NEURASTHENIA,    OR   NERVOUS    EXHAUSTION  509 

The  bowels  should  be  regulated.  A  careful  examination 
should  be  made  and  all  physical  abnormalities  should  be  cor- 
rected. Thus  adenoids,  enlarged  tonsils,  or  an  adherent  foreskin 
should  be  corrected  by  surgical  means.  The  child  should  be 
encouraged  to  exercise  control  over  his  emotions,  and  to  cultivate 
a  calm  temperament.  Care  should  be  taken  to  prevent  the 
formation  of  vicious  sexual  habits.  The  companions  and  friends 
of  the  child  should  be  carefully  chosen,  and  the  studies  should 
be  supervised  by  a  teacher  who  is  temperamentally  suited  to 
the  work.  As  the  child  grows  older,  or  in  the  case  of  young 
adults,  physical  ailments  should  receive  prompt  attention.  The 
nutrition  should  be  supervised,  and  good  mental  and  physical 
habits  be  acquired.  Somewhat  more  than  the  normal  amount 
of  physical  rest  should  be  taken,  and  mental  or  physical  over- 
work and  excitement  should  be  avoided.  An  occupation  should 
be  chosen  that  is  agreeable  to  the  individual,  and  that  will 
not  require  efforts  beyond  the  normal  capacity  of  the  patient. 
The  same  caution  as  regards  the  avoidance  of  overexertion, 
either  mental  or  physical;  the  cultivation  of  good  habits;  the 
avoidance  of  excitement;  the  taking  of  the  required  amount 
of  rest;  prompt  attention  to  all  physical  ailments,  and  the  cor- 
rection of  minor  physical  disabilities  should  be  insisted  upon  in 
all  individuals  who  show  a  tendency  to  abnormal  fatigability. 

In  the  treatment  of  this  condition  after  it  has  occurred  the 
first  and  most  important  factor  is  to  make  a  careful  and  thorough 
examination  to  discover  if  any  organic  disease  is  present.  If 
the  diagnosis  of  neurasthenia  has  been  made,  the  most  effective 
agent  at  our  disposal  that  is  capable  of  restoring  the  individual 
to  his  normal  state  is  rest;  rest  must  be  physical  and  mental, 
in  order  to  bring  about  beneficial  results.  The  amount  of  rest, 
and  what  constitutes  rest  for  different  individuals,  vary  in 
different  cases. 

In  markedly  debilitated  men,  in  many  children,  and  in  almost 
all  women  rest  in  bed  is  to  be  advised.  In  men  who  are  accus- 
tomed to  leading  an  active  life,  and  who  are  not  severely  debili- 
tated physically,  rest  in  bed  is  inadvisable,  as  these  patients 
are  in  a  state  of  constant  mental  rebellion. 

The  food  should  be  light  and  nutritious.     Hydrotherapy, 


5IO  MANUAL   OF   NERVOUS   DISEASES 

electricity,  and  massage  have  been  found  to  be  beneficial. 
The  bowels  must  be  kept  regular,  and  water  taken  freely.  The 
surroundings  of  the  patient  must  be  pleasant  and  the  room  well 
ventilated.  In  most  cases  it  is  important  to  have  a  competent, 
tactful  nurse,  and  to  exclude  the  family  and  friends.  Tonics 
and  laxatives  when  required  are  indicated. 

In  my  experience  the  most  effective  form  of  treatment,  and 
the  one  that  yields  the  promptest  and  most  satisfactory  results, 
is  the  Weir-Mitchell  rest  cure,  carried  out  in  a  properly  equipped 
hospital  or  sanatorium.    The  following  is  an  outline  of  such 
treatment,  and  should  be  modified  to  suit  the  individual  case: 
A  glass  of  cold  water.     Calisthenic  exercise,  five  minutes; 
deep    breathing    exercise;    Swedish    movements,    five 
minutes. 
Scotch  douche — patient  to  stand  in  warm  water;  sponge 
entire  body  alternately  with  hot  and  cold  water;  rub 
down  with  coarse  towel. 
Breakfast:   May  have  stewed  fruit — stewed  or  baked  apple, 
cranberry  sauce,  pineapple;  cereal,  any  sort,  with  plenty 
of  cream;  eggs  prepared  in  any  way;  toast  or  bread — 
plenty  of  butter;  milk  or  cocoa.    Eat  slowly,  masticate 
well. 
Rest  one  hour  after  breakfast. 
Exercise,  diversion,  or  occupation. 
Glass  of  cold  water;  nourishment. 
Rest. 

Dinner:    Must   not   have  the    same    dish    two    days    in 
succession.     May  have  broth,  meat,  chicken,  or  squab; 
vegetables — potatoes,  carrots,  spinach,  peas,  beets,  cauli- 
flower,  celery,    string-beans;   potatoes   may  be   boiled, 
riced,  mashed,  in  the  form  of  potato  cakes,  baked,  packed 
in  half -shell.     Salad — fruit  salad,  plain  lettuce  (no  dress- 
ing), asparagus,  beets;  bread   and  butter,  half -pint  of 
milk  flavored  with  tea. 
Rest  two  hours  after  dinner. 
Glass  of  cold  water;  nourishment. 
Diversion,  occupation,  exercise,  or  general  massage. 
Rest. 


PS  YCHASTHENIA  5  ^  ^ 

Supper:  Chops  or  other  meats  or  eggs;  sweetbreads; 
vegetables — potatoes,  mashed,  baked,  or  any  style 
which  patient  did  not  have  at  dinner;  one  other  vege- 
table which  patient  did  not  have  at  dinner;  toast  or 
bread  and  butter;  light  desert  or  stewed  fruit;  milk  or 
cocoa. 

Rest. 

Exercise,  diversion. 

Cold  pack,  hot  pack,  or  salt  rub — use  table  salt,  which  is 
to  be  heated;  moisten  hand,  take  a  handful  of  salt,  and 
rub  entire  body,  beginning  with  feet,  and  rubbing  always 
in  the  direction  of  the  venous  circulation;  abdomen  is  to 
be  rubbed  with  a  circular  motion,  beginning  in  lower 
right  quadrant. 

Cup  of  hot  milk  before  retiring. 

Sleep  in  well- ventilated  room;  bowels  to  be  kept  well  open; 
avoid  coffee,  tea,  tobacco,  alcohol,  fried  foods,  and  heavy 
pastries. 
If  patient  is  poorly  nourished,  the  amount  of  milk  is  to  be  in- 
creased until  tw^o  quarts  or  more  are  taken  daily.     It  should  be 
given  preferably  immediately  after  meals.     Sodium  citrate  may 
be  added  to  the  milk — 5  grains  to  each  |  pint  of  milk. 


PSYCHASTHENIA 

In  this  condition  there  exists  an  abnormal  state  of  the  mind 
in  which  the  individual  is  governed  by  ideas  which  obtrude 
themselves  more  or  less  persistently  upon  the  consciousness, 
and  w^hich  may  or  may  not  be  constantly  present.  These  ideas 
have  marked  effect  upon  the  emotional  tone  of  the  patient, 
usually  giving  rise  to  a  more  or  less  persistent  state  of  anxiety, 
w^ith  some  depression.  As  a  general  rule  the  patient  realizes 
the  falsity  of  his  conceptions  and  the  abnornality  of  these  ideas, 
struggles  against  them,  but  is  unable  to  prevent  their  occurrrence, 
or  to  subvert  the  over^^helming  influence  they  exert  upon  his 
emotions,  feelings,  and  actions. 

The  true  psychasthenic  is  not  insane,  for  he  realizes  the 


512  MANUAL   OF  NERVOUS  DISEASES 

absurdity  of  his  ideas.  Illusions,  hallucinations,  or  delusions 
are  not  present  in  psychasthenia. 

Etiology. — Heredity  plays  a  most  important  part  in  this 
disease.  In  the  great  majority  of  cases  there  is  a  history  of 
nervous  or  mental  troubles,  or  of  a  chronic  debilitating  disease 
in  the  immediate  ancestry.  Many  of  these  patients  also  show 
stigmata  of  degeneration.  Women  are  affected  somewhat  more 
often  than  men.  The  disease  develops  most  frequently  be- 
tween the  twentieth  and  the  fortieth  year. 

The  same  predisposing  and  exciting  causes  that  are  present 
in  neurasthenia  are  active  also  in  this  condition.  Among  the 
exciting  causes  are  excessive  fatigue,  sexual  or  alcoholic  excesses, 
trauma;  the  periods  of  puberty,  adolescence,  and  the  climac- 
terium; sensations  connected  with  the  heart,  stomach,  genital 
organs,  vertigo,  etc.,  which  are  accompanied  by  fear  of  serious 
disease;  strong  religious  emotions,  fright  or  fear,  grief,  prolonged 
worry,  great  anxiety,  etc.  Marked  emotional  disturbances, 
either  sudden  or  prolonged,  which  are  characterized  by  a  dis- 
agreeable tone  and  a  sense  of  fear,  in  a  predisposed  individual, 
serve  as  a  most  prominent  exciting  cause. 

A  thorough  examination  of  patients  suffering  from  psychas- 
thenia, and  a  careful  investigation  as  to  the  cause  of  some  of  the 
symptoms,  will  undoubtedly  convince  one  that  Freud's  theory  of 
psychic  trauma,  whether  or  not  of  a  sexual  nature,  with  con- 
sequent repression  and  submergence  into  unconsciousness, 
explains  the  underlying  cause  of  this  condition  in  some 
cases. 

Symptoms. — ^The  emotional  state  of  the  psychasthenic  is 
always  one  of  more  or  less  persistent  anxiety.  These  individuals 
are  apprehensive,  and  are  worried  as  to  the  outcome  of  their 
condition.  Sensations  referred  to  the  various  organs  are  ac- 
companied by  marked  mental  distress.  Thus  those  who  have 
palpitation  of  the  heart  or  a  sense  of  pressure  in  the  epigastric 
region  are  fearful  of  sudden  death  or  of  attacks  of  angina  pectoris; 
those  who  have  pain  in  the  head,  that  some  brain  disease  exists; 
those  who  have  attacks  of  vertigo,  that  they  are  going  to  suffer 
a  stroke  of  apoplexy,  etc. 

Persistent  morbid  fears  and  emotional  obsessions  are  among 


PSYCHASTHENIA  513 

the  most  common  symptoms.  These  patients  complain  of  a 
sense  of  discomfort,  fear,  great  apprehension,  and  anxiety  under 
certain  conditions.  They  realize  the  groundlessness  of  their 
fears,  and  yet  are  incapable  of  self-control  or  of  governing  their 
actions.  The  individual  may  be  afraid  to  go  out  alone  (mono- 
phobia), never  leaving  the  house  unless  accompanied  by  some 
one;  he  may  fear  to  go  into  confined  places  such  as  theaters  or 
churches  (claustrophobia) ;  may  dread  to  touch  a  knife  for  fear 
of  cutting  himself;  may  be  afraid  to  go  up  and  down  stairs  for 
fear  of  falling ;  there  may  be  a  fear  of  dirt  (mysophobia) ;  a  fear 
of  open  places  (agoraphobia) ;  a  fear  of  darkness  (nyctophobia) , 
etc. 

The  affected  individual  realizes  the  unreasonable  nature  of 
these  fears,  and  yet  is  powerless  to  prevent  their  disagreeable 
effect  or  to  exercise  control  of  himself  when  this  fear  exists. 
These  states  of  fear  are  frequently  accompanied  by  physical 
symptoms;  thus  the  individual  becomes  pale,  trembles,  and 
breaks  out  into  profuse  perspiration;  the  pulse  becomes  rapid, 
and  sometimes  diarrhea  or  vomiting  attacks  occur.  In  the  more 
severe  cases,  unless  relief  is  afforded,  all  the  evidences  of  collapse 
are  present. 

Imperative  Ideas. — Ideas  that  are  not  produced  by  association, 
but  start  up  independently  and  intrude  themselves  upon  the 
thoughts  so  forcibly  that  they  cannot  be  banished,  although 
they  are  recognized  by  the  patient  as  being  foreign  and  strange 
to  his  mental  personality,  are  termed  imperative  ideas. 

Ideas  foreign  to  one's  line  of  thought  often  intrude  themselves 
upon  the  consciousness  of  normal  individuals,  but  in  this  case 
they  are  quickly  dispelled,  and  do  not  cause  emotional  dis- 
turbance; in  the  psychasthenic,  on  the  other  ha.nd,  these  ideas 
intrude  themselves  upon  the  consciousness,  cannot  be  banished, 
and  cause  emotional  disturbance.  Thus,  for  example,  while  at 
prayer,  thoughts  of  sacrilegious  or  of  an  obscene  nature  may 
intrude  themselves  upon  the  consciousness  of  the  patient,  and 
cannot  be  banished,  occasioning  a  disagreeable  emotional  tone; 
or,  while  he  is  planning  some  pleasure  or  thinking  of  those  in 
whom  he  is  interested,  the  idea  of  death  or  of  accident  enters 
persistently  and  prominently  into  his  consciousness. 
33 


514  MANUAL   OF   NERVOUS   DISEASES 

Intellectual  Obsessions. — In  this  condition  there  occurs  a 
mental  state  in  which  the  patients  are  more  or  less  constantly 
in  a  state  of  doubt — it  is  impossible  for  them  to  reach  a  con- 
clusion, even  in  the  most  trivial  matters,  their  entire  time  being 
occupied  with  self-questioning  and  indecision. 

In  severe  cases  the  individual  is  so  dominated  by  his  obsessions 
that  he  is  practically  unable  to  devote  any  time  to  the  duties  of 
life.  The  mental  state  of  these  patients  is  distressing:  they 
realize  the  uselessness  and  absurdity  of  their  indecision,  and  yet 
cannot  resist  the  mental  processes  and  actions  which  it  occa- 
sions. These  patients  are  more  or  less  constantly  in  a  state  of 
fear  and  anxiety,  and  the  most  trivial  acts  of  life  are  carried 
on  only  after  a  prolonged  effort  and  indecision.  To  this  group 
of  symptoms  belongs  the  folie  du  doute  of  the  French:  the  pa- 
tient, upon  arising,  spends  hours  in  dressing,  and  it  is  only  with 
the  greatest  difficulty  that  he  is  able  to  make  up  his  mind  which 
tie  to  wear  or  which  suit  to  put  on,  dressing  and  undressing, 
until  finally  half  of  the  day  may  be  passed  in  indecision;  or 
if  he  must  copy  a  document,  he  spends  hours  in  going  over  the 
same  for  fear  of  an  omission;  after  retiring  for  the  night  he  will 
get  up  repeatedly  to  be  sure  that  he  has  locked  the  doors  or 
turned  out  the  lights. 

The  uncertainty  and  indecision  are  accompanied  by  fear, 
anxiety,  and  sometimes  by  such  physical  symptoms  as  cardiac 
palpitation,  profuse  perspiration,  trembling,  weakness,  dila- 
tation of  the  pupils,  etc. 

Morbid  Impulses — Volitional  Obsessions. — In  this  condition 
the  individual  is  deficient  in  will,  being  unable  to  restrain  him- 
self from  performing  certain  acts.  He  feels  an  uncontrollable 
desire  to  perform  some  act,  which  may  be  unconventional, 
dangerous  to  himself  or  others,  or  useless.  While  obsessed  by 
this  impulse  he  suffers  from  mental  discomfort  and  anxiety, 
which  are  followed  by  a  sense  of  relief  after  the  performance 
of  the  act.  As  examples  of  such  acts  may  be  mentioned  a 
feeling  that  he  must  count  every  animal  he  sees;  must  skip 
certain  words  in  sentences;  must  touch  certain  objects.  At 
other  times  these  impulses  assume  a  more  serious  character, 
and  the  patients  feel  that  they  must  take  objects  they  admire; 


PSYCHASTHENIA  515 

under    this    group    come   true   kleptomania   and    dipsomania. 
Others  feel  impelled  to  throw  objects  at  people,  etc. 

Among  other  symptoms  that  occur  less  frequently  are  states 
of  consciousness  in  which  the  patient  feels  as  if  he  were  not 
himself — he  is  obsessed  by  a  feeling  of  strangeness,  as  if  his 
attitude  toward  his  surroundings  had  been  altered.  In  more 
marked  cases  there  is  complete  change  of  personality,  and  the 
individual  no  longer  recognizes  himself  or  his  original  surround- 
ings; the  past  becomes  completely  obliterated,  and  he  possesses 
himself  of  an  entirely  new  personality,  and  reacts  differently 
from  his  original  self  to  his  surroundings.  This  state  may  last 
for  from  a  few  hours,  days,  weeks,  or  months  to  many  years, 
and  when  he  again  recovers  his  original  personality  he  has  no 
recollection  of  the  actions,  persons,  and  events  that  occupied 
him  during  the  period  when  he  was  in  a  state  of  abnormal  con- 
sciousness. 

The  psychasthenic  may  develop  along  with  the  neurasthenic 
state,  or  it  may  occur  in  an  individual  suffering  from  neuras- 
thenia; it  generally  develops  independently  o^  this  disease. 
Psychasthenia  may  also  be  complicated  by  or  complicate 
hysteria. 

Course. — ^This  disease  usually  begins  gradually,  but  may  be 
of  sudden  onset,  following  some  emotional  disturbance  or  in- 
jury. A  patient  who  develops  this  disease  shows  many  pecu- 
liarities early  in  life:  he  is,  as  a  rule,  peculiar,  scrupulous,  and 
has  difficulty  in  reaching  conclusions;  such  patients  are  sensi- 
tive, many  are  eccentric,  and  all  are  very  emotional  and  im- 
pressionable. 

In  cases  in  which  the  symptoms  are  of  slow  onset  the  indi- 
vidual himself  will  notice  that  there  is  a  certain  strangeness 
about  his  mental  activity;  that  his  physical  sensations  and  his 
mental  processes  are  accompanied  by  a  queer  emotional  change, 
and  finally  that  physical  sensations  induce  great  anxiety  and 
emotional  disturbances  which  he  is  powerless  to  prevent.  He 
realizes  that  his  actions  are  governed  by  thoughts  and  im- 
pulses that  come  unsolicited  and  that  he  is  unable  to  banish. 

The  disease  is  subject  to  remissions  and  exacerbations,  the 
patient  being  at  times  much  improved  and  almost  free  from 


5l6  MANUAL   OF   NERVOUS   DISEASES 

symptoms,  whereas  at  others  his  life  is  made  extremely  un- 
happy by  the  persistent  presence  of  many  disagreeable  symp- 
toms. 

Prognosis. — In  many  cases  the  outlook  is  serious,  the  disease 
lasting  for  years,  and  manifesting  a  tendency  to  the  develop- 
ment of  fixed  delusions.  On  the  other  hand,  some  cases  occur 
that  are  very  amenable  to  treatment  and  that  make  a  good 
recovery  within  a  reasonable  time.  In  still  other  cases,  as 
the  result  of  the  persistent  and  constant  presence  of  morbid 
impulses,  fixed  ideas,  etc.,  the  individual  isolates  himself  and 
leads  a  life  of  seclusion  and  unhappiness.  The  more  marked 
the  psychopathic  hereditary  tendencies  are,  and  the  more  un- 
suited  the  surroundings  for  carrying  on  the  proper  treatment, 
the  more  unfavorable,  as  a  rule,  is  the  prognosis. 

Diagnosis. — ^The  differentiation  is  made  from  neurasthenia 
by  the  fact  that  in  neurasthenia  the  symptoms  are  those  of 
fatigue,  either  mental  or  physical,  whereas  in  psychasthenia 
fatigue  symptoms  are  generally  absent,  and  characteristic 
mental  symptoms,  whose  true  import  the  patient  recognizes, 
are  present. 

From  hysteria  the  disease  is  differentiated  by  the  fact  that 
in  hysteria  symptoms  are  present  pointing  to  abnormal  physical 
functions,  such  as  paralysis,  contractures,  disturbances  of  sensa- 
tion, attacks  of  varying  character,  intervals  during  which  the 
individual  feels  perfectly  normal,  whereas  in  psychasthenia 
there  is  an  absence  of  these  symptoms  with  a  prominence  of  the 
characteristic  mental  symptoms. 

In  some  individuals  there  may  be  an  association  of  neuras- 
thenic and  psychasthenic  states,  or  of  hysteric  and  psychas- 
thenic states,  or  all  three  conditions  may  be  combined. 

From  true  insanity  psychasthenia  is  differentiated  by  the 
fact  that  in  the  latter  the  individual  clearly  perceives  his  ab- 
normality, and  often  realizes  the  absurdity  of  his  symptoms, 
whereas  in  insanity  the  patient  is  incapable  of  realizing  the 
true  import  or  absurdity  of  his  symptoms. 

Treatment. — A  careful  examination  must  be  made  so  as  to 
exclude  all  organic  diseases  and  in  order  to  gain  the  individual's 
confidence.    It  is  well  to  explain  frankly  to  the  patient  the 


ANXIETY   NEUROSIS  517 

nature  of  his  disease,  and  to  secure  his  cooperation  in  the  treat- 
ment. All  physical  defects  should  be  corrected,  and  the 
general  physical  condition  of  the  patient  looked  after,  in  the 
same  manner  in  which  the  neurasthenic  is  treated. 

In  some  individuals  suitable  occupation,  diversion,  and  sug- 
gestion are  sufl&cient  to  bring  about  marked  improvement  or 
cure.  In  others,  in  addition  to  occupation,  diversion,  rest,  etc., 
a  system  of  gradual  mental  and  temperamental  reeducation 
should  be  begun.  In  still  another  group  of  cases  good  results 
can  be  obtained  only  by  means  of  psychanalysis,  laying  bare 
the  submerged  irritants,  and  bringing  them  again  into  the 
consciousness,  together  with  the  eradication  of  the  mental 
traumas  that  are  at  the  root  of  the  psychasthenic  state.  In 
many  cases  one  must  use  all  these  means  to  bring  about  a 
favorable  result. 

The  treatment  must  usually  extend  over  a  prolonged  period, 
sometimes  lasting  years.  It  is  most  important,  in  the  treatment 
of  this  condition,  that  the  patient  have  some  suitable  occupation 
or  diversion  which  should  occupy  much  of  his  time;  physical 
work,  such  as  farming  and  mechanical  labor,  painting,  drawing, 
etc.,  are  all  to  be  advised. 

Treatment  by  psychanalysis  is  applicable  only  to  a  limited 
number  of  cases ;  these  should  be  selected  only  after  a  very  care- 
ful consideration  as  regards  the  possible  harm  that  may  be  done, 
and  should  be  carried  out  only  by  those  who  are  experienced  in 
this  line  of  therapy. 

ANXIETY  NEUROSIS 

In  almost  every  form  of  psychoneurosis  a  state  of  mental 
anxiety  is  more  or  less  constantly  present  to  a  greater  or  less 
degree,  but  this  anxiety  is  usually  secondary  to  fear  which  is 
aroused  by  the  presence  of  other  symptoms. 

A  condition  is  occasionally  seen  in  which  the  general  state  of 
anxiety  is  constantly  present,  and  which  is  associated  with  all 
the  mental  and  physical  activities  of  the  individual.  Such 
persons  are  not  true  psychasthenics,  hysterics,  or  neurasthenics: 
they  live  in  constant  anxiety,  placing  a  pessimistic  interpretation 


5l8  MANUAL   OF  NERVOUS   DISEASES 

on  all  abnormal  sensations  or  occurrences.  They  are  usually 
depressed,  and  show  a  general  irritability.  As  in  the  other 
psychoneuroses,  the  chief  cause  of  this  condition  is  hereditary 
taint.  The  course  of  this  neurosis  is  chronic.  The  outlook  for 
recovery  is  very  gloomy,  as  it  is  difficult  to  alter  the  temperament 
of  these  individuals.  Prolonged  treatment  may  bring  about 
some  improvement.  In  some  cases  psychanalysis  relieves  the 
causative  psychic  trauma,  and  may  be  followed  by  improve- 
ment or  recovery. 

OCCUPATION   NEUROSIS— OCCUPATION   SPASMS 

This  condition  is  characterized  by  the  occurrence  of  pain, 
weakness,  tremor,  or  cramp,  or  any  combination  of  these  states, 
in  certain  muscles  or  groups  of  muscles.  The  symptoms  appear 
only  when  these  muscles  are  called  upon  to  perform  some  ac- 
customed occupational  movements,  but  do  not  occur  when  these 
muscles  or  groups  of  muscles  perform  other  movements  than 
those  connected  with  the  accustomed  occupation. 

The  more  delicate  and  highly  differentiated  the  movements 
that  enter  into  the  performance  of  the  occupation,  the  more 
readily  does  the  overuse  of  these  muscles  set  up  this  condition. 

It  occurs  more  frequently  in  the  upper  extremities,  but  may 
affect  any  part  of  the  body.  The  most  common  forms  are  those 
connected  with  writing  and  the  occupation  of  telegrapher, 
typist,  pianist,  violinist,  trumpet-player,  dancer,  seamstress, 
cutter,  blacksmith,  milker,  etc. 

Etiology. — In  the  vast  majority  of  cases  a  neuropathic  heredity 
is  present.  Many  of  these  individuals  are  also  neurasthenics. 
Not  infrequently  the  condition  occurs  in  more  than  one  member 
of  a  family.  While  the  neurosis  itself  is  not  directly  transmitted, 
a  tendency  toward  either  local  or  general  fatigability  of  the 
nervous  system  may  be  inherited,  which  evidences  itself  when 
there  is  general  or  local  overuse  of  the  muscles  under  unfavorable 
conditions.  Any  occupation  that  requires  repeated,  continuous, 
and  prolonged  movements  which  are  limited  in  extent  and  which 
are  of  a  purely  voluntary  character,  when  carried  on  under  un- 
favorable conditions  in  a  predisposed  individual,  may  be  followed 


OCCUPATION    NEUROSIS — OCCUPATION    SPASMS         519 

by  the  development  of  this  condition.  It  may  also  occur  after 
injury  or  following  any  debilitating  disease.  It  occurs  more 
frequently  in  young  adults,  but  may  be  present  in  childhood. 
It  is  also  more  likely  to  occur  when  work  is  carried  on  under 
physical  or  mental  strain. 

Pathology. — Careful  examination  has  failed  to  reveal  organic 
changes  in  either  the  nervous  or  the  muscular  system,  and  this 
condition  must,  therefore,  be  classified  with  the  functional 
neuroses. 

Symptoms. — ^The  disease  is  usually  insidious  in  onset.  At 
first  the  individual  notices  that  the  movements  connected  with 
his  occupation  are  carried  on  with  some  little  difficulty  or  dis- 
comfort, which  occurs  only  at  intervals,  and  usually  only  when 
his  attention  is  directed  toward  the  muscular  movements 
incident  to  his  occupation,  or  when  extra  effort  is  demanded  of 
him.  The  distribution  of  the  symptoms  is  dependent  upon  the 
occupation:  thus  in  WTiters'  cramp,  pianists'  cramp,  seamstresses' 
cramp,  milkers'  cramp,  etc.,  the  hands  and  fingers  are  involved; 
in  blacksmiths'  cramp  the  shoulder  muscles  are  affected,  and 
in  dancers'  cramp  the  calf  muscles  are  involved. 

The  condition  may  manifest  itself  in  several  ways :  in  the  most 
common  form  the  individual  notices  that  he  tires  more  readily 
than  usual,  and  that  he  cannot  carr}'  on  his  occupation  with  his 
occustomed  speed ;  also  that  there  is  hesitation  in  his  movements, 
which  interferes  with  his  w^ork.  Gradually,  in  the  course  of  his 
occupation,  spasms  of  the  muscles  develop. 

At  first,  in  spite  of  this  spasmodic  condition,  the  patient  can 
continue  his  occupation,  but  gradually  the  difficulty  increases, 
and  any  movement  connected  with  his  occupation  occasions  a 
spasm.  The  more  he  thinks  about  his  work,  and  the  greater  the 
effort  he  puts  forth  to  continue  his  work,  the  more  marked  does 
the  interference  become. 

If  this  disease  attacks  writers,  the  spasm  affects  the  flexors 
of  the  fingers,  especially  those  of  the  thumb  and  the  index- 
finger,  and  gradually  extends  to  the  muscles  of  the  hand  and 
forearm.  In  attempting  to  write,  the  letters  are  irregularly 
formed,  interrupted,  and  very  uneven  in  size.  In  other  occupa- 
tions the  same  disturbances  take  place:  at  first  the  spasms  are 


520  MANUAL   OF   NERVOUS   DISEASES 

mild  in  character  and  limited  in  distribution;  if,  however,  the 
occupation  is  continued  and  the  attention  is  centered  upon  the 
effort  to  carry  on  the  work,  the  spasms  increase  in  severity 
and  the  distribution  becomes  more  extensive. 

Spasm  is  not  the  only  manifestation  of  the  neurosis:  in  some 
individuals,  instead  of  spasm,  tremor  develops,  a  combination 
of  spasm  and  tremor  being  somewhat  common.  In  another 
group  of  cases  instead  of  spasms  a  simple  weakness  becomes 
evident;  this  is  known  as  the  paralytic  form,  and  is  quite  un- 
common. If  the  occupation  is  persisted  in  the  necessary  move- 
ments finally  become  impossible,  and  when  an  effort  is  made  to 
perform  these  movements,  a  relaxation  of  the  muscles  occurs 
together  with  an  inability  to  cause  a  voluntary  contraction  to 
effect  the  necessary  movements. 

A  sensory  or  neuralgic  form  of  occupation  neurosis  is  also 
encountered.  In  the  spasmodic  form  pain  very  frequently 
attends  the  muscle  spasm,  giving  rise  to  a  true  cramp;  but  in 
the  neuralgic  form  the  occupational  movements  may  cause  pain, 
which  in  itself  may  be  so  severe  as  to  interfere  with  the  carrying 
on  of  the  occupation,  there  being  a  complete  absence  of  muscle 
spasm. 

The  objective  examination,  as  a  rule,  yields  a  negative  result. 
The  tendon  reflexes  are  often  increased,  but  there  is  no  dis- 
turbance of  sensation  or  motion  and  no  tenderness;  the  symptoms 
manifest  themselves  only  upon  the  effort  to  perform  the  move- 
ments that  are  concerned  with  the  individual's  occupation. 

Course. — The  course  of  the  disease  is  usually  slow;  the  onset 
is  gradual,  and  the  condition  persists  for  a  long  time.  The 
prognosis  is  not  very  favorable,  for  even  after  recovery  has 
taken  place  relapses  frequently  occur.  In  the  sensory  form  the 
prognosis  is  better.  The  longer  the  duration  of  the  disease,  the 
more  unfavorable  is  the  prognosis. 

The  diagnosis  is  usually  made  without  difficulty.  Care  should 
be  exercised  that  the  onset  of  an  organic  disease  is  not  overlooked. 
Occupation  neurosis  must  be  diagnosed  from  hysteric  states  in 
which  the  patient  is  unable  to  follow  his  usual  vocation;  as  a 
rule,  there  is  little  difficulty  in  making  the  differentiation.  The 
presence  of  other  symptoms  of  hysteria  and  a  careful  consider- 


OCCUPATION   NEUROSIS — OCCUPATION   SPASMS         52 1 

ation  of  the  history  of  the  onset  and  the  progress  of  the  con- 
dition usually  enable  one  to  arrive  at  a  correct  diagnosis. 

In  the  hysteric  and  neurasthenic  states  the  difficulty  or  in- 
ability to  carry  out  local  voluntary  movements  is  not  limited  to 
the  special  movements  required  in  a  certain  occupation,  but 
occurs  with  all  voluntary  muscular  contractions. 

Treatment. — The  patient  should  be  promptly  advised  to 
discontinue  the  occupation.  The  individual's  general  health 
should  be  looked  after.  Massage  and  special  calisthenics  are  of 
great  benefit;  the  patient  should  be  instructed  to  carry  out  all 
movements  in  a  free  and  graceful  manner,  avoiding  all  cramped 
positions.  If  the  occupation  is  again  resumed,  the  necessary 
movements  should  be  carried  on  under  different  conditions 
and  in  a  different  manner  than  they  were  at  the  time  the  in- 
dividual was  affected. 

Drugs  are  of  little  value.  Special  forms  of  apparatus  are 
made  that  afford  support  to  the  muscles  in  certain  forms  of 
occupation  neurosis ;  this  is  especially  true  in  the  case  of  writers' 
cramp,  for  which  a  special  splint  to  support  the  wrist  and  fingers 
is  used. 


NEUROSIS  CHARACTERIZED  BY  SPASMODIC 
MUSCLE   CONTRACTIONS 

Localized  Muscle  Spasms. — Under  this  head  will  be  considered 
those  abnormalities  of  movement  that  are  limited  to  a  muscle  or 
to  a  group  of  muscles  which  are  supplied  by  one  or  more  nerves, 
the  contraction  being  due  either  to  irritation  of  the  nerv^es 
themselves  or  refiexly  to  centers  in  the  anterior  horn  or  the  higher 
cerebral  centers.  Such  muscle  contractions  are  not  necessarily 
purposive  in  character,  nor  is  it  always  possible  to  reproduce  them 
voluntarily.  They  differ  from  the  tics  in  that  the  latter  are 
the  result  of  contractions  of  groups  of  muscles  whose  combined 
action  brings  about  a  voluntary  or  purposive  act.  The  tic 
can  always  be  reproduced  voluntarily, 

FACIAL   SPASM 

Spasmodic  contraction  of  the  muscles  supplied  by  the  facial 
nerve  or  nerves  is  probably  the  form  seen  with  the  greatest 
frequency. 

Etiology. — ^This  condition  occurs  generally  in  adult  life, 
and  more  frequently  in  women  than  in  men.  As  a  rule,  a  neuro- 
pathic disposition  exists  in  the  individual.  The  condition  has 
been  known  to  occur  after  sudden  emotional  shocks.  It  is  a 
well-known  fact  that  muscle  contractions  occur  as  the  result 
either  of  a  reflex  sensory  irritation  or  of  a  voluntary  impulse, 
or  it  may  be  the  result  of  some  involuntary  coordinative  activity. 
It  is  in  consequence  of  the  uninhibited  activity  in  the  first- 
named  condition  that  facial  spasm  occurs;  consequently  the  com- 
moner causes  of  this  condition  are  sensory  irritations  in  the  region 
supplied  by  the  fifth  nerve,  such  as  irritative  conditions  in  the 
nose,  throat,  mouth,  scalp,  teeth,  eyes,  ears,  etc.;  refractive 
errors,  local  disease  of  the  eyelids,  etc.,  may  also  produce  this 
condition. 
522 


FACIAL   SPASM  523 

Facial  spasm  occurs  with  special  frequency  in  facial  neuralgia. 
Irritative  lesions  in  facial  areas  in  the  precentral  convolution  of 
the  brain  may  cause  spasmodic  movements  which  start  in  the 
face  and  gradually  extend  until  the  entire  side  of  the  body  is 
involved,  thus  giving  rise  to  Jacksonian  epilepsy.  Tumor  of 
the  facial  nerves  or  an  irritative  condition  at  the  base  of  the 
brain  may  also  give  rise  to  facial  spasms.  Irritative  affections 
of  other  parts  of  the  nervous  system  may  sometimes  be  the 
cause  of  facial  spasm.  Clonic  twitchings  of  the  muscles  supplied 
by  the  facial  nerves  may  sometimes  precede  a  facial  paraylsis. 

Pathology. — In  the  great  majority  of  cases  facial  spasm  has 
no  pathologic  basis ;  in  a  few  cases  organic  changes  of  an  irritative 
nature  may  be  present,  occurring  in  the  course  of  the  nerve,  in 
the  middle  ear,  at  the  base  of  the  brain,  in  the  medulla,  or  may 
involve  the  brain  itself. 

Symptoms. — The  principal  s}Tnptom  of  this  condition  is  a 
sudden,  lightning-like  contraction  of  the  muscles  of  the  face. 
The  contraction  occurs  at  inter^^als,  or  a  series  of  contractions 
may  occur  rapidly,  a  longer  inter\'^al  existing  between  each 
paroxysm. 

This  disease  is  at  first  usually  limited  to  one  side  of  the  face, 
but  both  sides  may  eventually  be  involved.  Either  all  or  some 
of  the  muscles  supplied  by  the  facial  ner\'e  may  be  affected. 
The  muscle  most  frequently  involved  is  the  orbicularis  palpe- 
brarum, but  the  zygomatic  muscles  and  the  levator  anguli  oris 
are  often  affected  along  with  the  muscles  of  the  eyelid.  Some- 
times the  spasm  involves  the  muscles  of  the  mouth  and  chin, 
and  in  some  cases  all  the  muscles  of  one  side  of  the  face  becoine 
affected.  Occasionally,  in  addition  to  the  clonic,  lightnmg-like 
contractions,  tonic  contractions  occur  in  which  the  muscles 
remain  contracted  for  several  seconds.  Under  these  conditions 
the  eyelids  are  closed,  the  forehead  is  thrown  into  furrows,  and 
the  nose  and  mouth  are  drawn  to  the  side  of  the  face  affected. 
These  muscle  contractions  are  usually  least  marked  during 
mental  and  physical  rest,  and  are  exaggerated  and  intensified 
by  physical  exertion,  excitement,  and  any  sensory  stimulation 
of  the  fifth  nerve  or  those  nerves  capable  of  reflexly  stimulating 
the  seventh  nerve;  thus  the  spasms  increase  when  talking  or 


524  MANUAL   OF   NERVOUS   DISEASES 

eating,  on  exposure  to  cold  drafts,  on  efforts  to  examine  the 
patient's  eyes  or  throat,  etc. 

Vasomotor  and  trophic  disturbances  are  rarely  present.  The 
spasm  itself  is  never  painful,  and  some  individuals  are  not  even 
conscious  of  these  twitchings.  The  voluntary  movements  of 
the  facial  muscles  are  not,  as  a  rule,  affected,  but  the  spasm  may 
occur  during  these  movements  and  disturb  their  course ;  in  some 
cases  efforts  to  move  the  facial  muscles  voluntarily  bring  on  or 
increase  the  symptoms. 

The  tonic  spasm  that  is  limited  to  the  muscles  that  close  the 
eyes  is  termed  blepharospasm;  this  may  be  unilateral  or  bilateral. 
The  clonic  form,  known  as  blepharoclonus,  is  not  uncommon. 

Course. — ^This  disease  usually  runs  a  chronic  course.  The 
spasms  begin  in  a  few  muscles,  and  extend  until  the  entire  face 
is  involved.  The  disease  is  especially  subject  to  remissions; 
the  intermissions  or  remissions  may  come  on  suddenly  and  last 
for  variable  periods  of  time,  but  there  is  a  great  tendency  for 
the  condition  to  recur. 

Prognosis. — ^The  prognosis  is  unfavorable.  A  few  cases  have 
been  known  in  which,  either  spontaneously  or  as  the  result  of 
treatment,  recovery  took  place  within  a  short  time.  If  the 
condition  has  become  firmly  established,  the  prospects  for 
recovery  are  very  slight;  even  if  intermissions  should  occur,  the 
probabilities  are  that  the  spasms  will  recur  and  continue,  with 
remission,  throughout  the  patient's  life. 

Diagnosis. — ^This  condition  must  be  differentiated  from  an 
irritating  tumor  at  the  base  of  the  brain,  from  Jacksonian 
epilepsy,  and  from  facial  tic.  In  the  first  two  conditions  the 
diagnosis  is  readily  made  from  the  occurrence  of  other  symptoms, 
indicating  the  presence  either  of  some  irritative  disease  at  the 
base  of  the  brain  or  of  an  irritative  condition  involving  the 
cerebral  cortex.  From  facial  tic  the  diagnosis  is  readily  made 
when  one  remembers  that  a  tic  is  a  complex,  purposive  act  which 
can  be  temporarily  arrested,  and  which  is  often  preceded  by  an 
impulse  to  perform  this  act,  and  which  eventually  cannot  be 
resisted;  that  after  the  occurrence  of  the  muscle  contractions 
there  is  a  sense  of  relief;  that,  on  the  other  hand,  facial  spasm 
is  a  reflex  contraction  of  muscles  supplied  by  the  seventh  nerve, 


FACIAL    SPASM  525 

the  contraction  coming  on  without  warning.  Generally,  as 
the  result  of  his  efforts  to  avoid  the  contractions,  they  occur 
with  greater  frequency  and  increased  severity;  moreover,  the 
movements  of  facial  tic  can  be  voluntarily  reproduced  by  the 
patient,  whereas  the  movements  of  a  facial  spasm  cannot,  as 
a  rule,  be  voluntarily  reproduced. 

Treatment. — It  is  important,  in  these  cases,  to  make  a  most 
careful  examination,  to  discover,  if  possible,  a  focus  from  which 
a  sensory  reflex  irritation  could  arise.  In  this  examination  one 
must  keep  in  mind  the  fact  that  these  sensory  irritations,  al- 
though present  most  often  in  the  area  supplied  by  the  fifth 
nerve,  may  yet  occur  at  some  distance.  The  throat,  nose, 
teeth,  eyes,  ears,  scalp,  etc.,  should  be  carefully  examined,  and 
if  any  evidence  of  abnormality  is  present,  it  should  if  possible 
be  corrected.  Careful  examination  should  also  be  made  of  the 
respiratory,  cardiac,  abdominal,  and  pelvic  organs,  and  abnormal 
conditions  found  should  also  be  rectified  if  possible. 

In  cases  where,  after  the  correction  of  all  physical  defects, 
no  relief  follows,  it  may  be  advisable  to  attempt  to  ascertain  if 
the  irritation  arises  from  some  of  the  smaller  filaments  of  the 
fifth  nerve.  For  this  purpose  it  is  permissible  to  inject,  at 
different  times,  the  supra -orbital,  the  superior  maxillary,  and  the 
inferior  maxillary  nerves  with  a  w^ak  solution  of  cocain.  This 
is  done  for  diagnostic  purposes,  to  ascertain  whether  the  spasm 
can  be  temporarily  inhibited.  If  one  is  fortunate  enough  to 
discover  the  irritation  in  one  of  these  branches  of  the  fifth  nerve, 
the  subsequent  injection  of  the  affected  nerve  with  alcohol, 
according  to  the  method  of  Schlosser,  may  bring  about  per- 
manent beneficial  results. 

In  those  cases  that  are  not  relieved  by  the  foregoing  procedure 
other  measures  must  be  used  in  the  endeavor  to  give  the  patient 
relief.  If  the  patient  is  of  a  neuropathic  constitution,  he  should 
receive  appropriate  treatment  in  the  form  of  rest,  proper  diet, 
exercise,  hydrotherapy,  etc.  Hot  applications  to  the  face  and 
the  free  use  of  sedatives  are  indicated.  Bromids,  cannabis 
indica,  hyoscin,  atropin,  and,  under  some  conditions,  morphin 
may  also  be  used. 


526  MANUAL   OF   NERVOUS  DISEASES 

SPASMS   OF  THE   MUSCLES   OF   MASTICATION 

Spasms  limited  to  the  muscles  of  mastication  are  not  common. 
They  may  be  of  the  tonic  or  the  clonic  type.  Tonic  spasms 
limited  to  the  muscles  of  mastication  may  be  a  symptom  of 
tetanus,  meningitis,  tetany,  or  epilepsy.  They  occur  reflexly, 
as  the  result  of  an  inflammatory  condition  of  the  temporomaxil- 
lary  fossa  or  its  neighborhood,  irritative  conditions  in  the  mouth, 
such  as  an  unerupted  wisdom  tooth,  as  an  evidence  of  hysteria, 
etc.  Clonic  spasms  of  the  masseter  muscles  occur  in  chills, 
hysteria,  epilepsy,  neuralgia,  ear  disease,  etc. 

The  prognosis  of  the  spasms  of  the  masseter  muscles  is  usually 
good  if  the  cause  can  be  discovered  and  removed.  Treatment 
should  be  directed  toward  the  discovery  and  removal  of  the 
cause. 

SPASMODIC   TORTICOLLIS 

Spasms  in  the  muscles  of  the  neck  maybe  unilateral  or  bilateral. 
They  may  be  limited  to  individual  muscles  or  to  several  muscles 
of  one  or  of  both  sides.  The  muscles  supplied  by  the  spinal 
accessory  nerve  are  especially  likely  to  be  affected.  The  spasms 
which  may  begin  in  the  muscles  supplied  by  one  nerve  do  not, 
as  a  rule,  show  a  tendency  to  become  limited,  but  are  apt  to 
spread  to  other  muscles  during  the  course  of  the  disease. 

Etiology. — This  disease  is  especially  liable  to  affect  individuals 
of  a  neuropathic  or  psychopathic  constitution.  A  direct  he- 
reditary transmission  is,  however,  rare. 

Reflex  irritations  from  the  fifth  nerve  and  occipital  nerve, 
refractive  errors,  organic  diseases  of  the  brain,  disease  of  the 
interna]  ear,  chronic  poisoning  from  alcoholic  and  metallic 
substances,  infectious  diseases,  influenza,  typhoid,  pneumonia, 
mental  or  physical  overexertion,  shock,  exposure,  rheumatism, 
etc.,  are  among  the  possible  causes.  The  disease  occurs  more 
frequently  in  women  than  in  men,  and  may  appear  at  any  time 
in  life,  although  it  occurs  with  greatest  frequency  after  the 
thirtieth  year. 

Pathology. — No  organic  changes  in  the  central  or  peripheral 
nervous  system  are  found.  According  to  views  expressed  by 
Brissaud  and  Oppenheim,  this  disease  is  due  to  a  condition  of 


SPASMODIC    TORTICOLLIS  527 

irritation  in  the  nerve  centers  situated  in  the  cortex  of  the  brain, 
both  in  the  motor  and  in  the  sensory  zone  that  corresponds  to 
the  cervical  muscles;  these  observers  assert  that  the  instability 
of  these  centers,  which  is  mostly  inherited  or  congenital,  is  the 
cause  of  the  disease. 

The  symptoms  depend  upon  the  extent  of  the  muscular 
involvement — whether  one  or  both  sides  are  involved,  and 
whether  the  spasmodic  contractions  are  clonic,  tonic,  or  mixed. 
As  a  rule,  the  clonic  twitchings  are  associated  with  a  transient 
tonic  contraction  of  the  muscles.  If  the  muscles  of  one  side  are 
affected  during  the  contraction,  the  face  may  be  turned  toward 
the  other  side;  the  ear  approaches  the  clavicle,  and  the  chin  is 
raised;  as  a  rule,  the  contractions  cause  only  a  rotation  of  the 
head  to  the  opposite  side.  If  both  sides  are  affected,  the  head 
is  thrown  backward,  and  there  is  a  wrinkling  of  the  forehead; 
again,  the  spasms  may  extend  to  the  muscles  of  the  shoulder 
and  arm,  in  which  case,  when  the  head  is  rotated  away  from 
the  side  of  the  spasm,  the  shoulder  is  elevated  and  the  arm  is 
abducted.  In  some  cases  the  spasmodic  contraction  may  be 
so  slight  that  the  movements  of  the  head  are  hardly  noticeable; 
in  other  cases  the  contractions  are  so  violent  that  the  head  is 
either  thrown  backward  or  rotated  and  thrown  to  the  side  with 
great  force.  In  fact,  these  movements  may  be  so  constant  and 
forcible  that  speaking,  eating,  and  sleeping  are  all  rendered 
difficult.  The  muscles  affected  may  become  h}^ertrophied. 
In  some  cases  the  spasmodic  seizures  are  present  almost  con- 
tinuously, occurring  in  paroxysms,  with  a  tonic  contraction  as 
a  termination.  In  these  severe  cases  there  are  usually  remissions 
during  which  the  condition  is  not  so  severe.  In  some  the  spas- 
modic seizures  occur  in  the  form  of  attacks,  separated  by  inter- 
vals during  which  the  spasms  are  completely  absent.  The 
condition  is  aggravated  by  emotion,  physical  exertion,  observa- 
tion, etc.  The  spasms  may  cease  entirely  when  the  individual  is 
in  the  recumbent  position,  and  be  present  only  when  he  is  in 
the  erect  posture.  In  some  cases  the  spasm  can  be  temporarily 
arrested  by  making  pressure  upon  certain  points  of  the  neck  or 
head  or  by  holding  the  chin,  etc. 

As  a  rule,  pain  is  not  present,  but  many  of  these  patients 


528  MANUAL   OF  NERVOUS   DISEASES 

complain  of  an  aching  sensation  in  the  neck  and  shoulders. 
There  is  no  evidence  of  paralysis  nor  any  disturbance  of  sensa- 
tion. As  a  rule,  the  spasmodic  contractions  cease  during  sleep, 
but  this  is  not  invaraibly  the  case.  Mental  disturbances  are 
sometimes  associated  with  these  spasms. 

Occasionally  depression  and  anxiety  precede  the  disease,  and 
in  some  rare  cases  the  spasmodic  seizures  cease  and  mental 
symptoms  appear,  with  the  recurrence  of  the  spasmodic  con- 
dition after  the  mental  symptoms  disappear. 

Course. — ^The  disease  is  essentially  chronic  in  its  course. 
It  is  marked  by  remissions  and  intermissions  that  may  last  for 
variable  periods  of  time.  In  some  cases,  owing  to  the  difficulty 
in  eating  and  to  the  interference  with  sleep,  marked  physical 
deterioration  and  loss  of  weight  take  place.  The  disease  lasts 
for  years.  It  attains  a  certain  degree  of  severity,  remains 
stationary,  or  may  vary  in  intensity.  The  condition  may  become 
so  distressing  as  to  lead  to  attempts  at  suicide. 

Prognosis. — ^The  prognosis  is  extremely  unfavorable.  The 
younger  the  individual,  the  shorter  the  duration  of  the  condition, 
and  the  less  severe  the  spasms,  the  more  promising  is  the  outlook 
for  recovery.  In  those  cases  in  which  some  direct  relation  can 
be  established  between  sensory  irritation  of  the  occipital  or 
fifth  nerve  and  the  spasmodic  torticollis,  a  more  favorable 
prognosis  is  presented.  In  those  cases  that  occur  in  individuals 
who  present  hysteric  symptoms  the  prognosis  is  less  favorable. 
The  older  the  individual,  the  longer  the  duration,  and  the  more 
severe  the  spasms,  the  graver  is  the  outlook. 

Diagnosis. — ^This  condition  is  distinguished  from  rheumaiic 
torticollis  by  the  severe  pain  and  tenderness  of  the  muscles  to 
pressure  and  by  the  pain  on  movement.  Pain  and  tenderness 
are  absent  in  spasmodic  torticollis.  From  congenital  torticollis 
it  is  differentiated  by  the  fact  that  the  condition  is  present  from 
birth  and  that  secondary  changes  occur  in  the  cervical  vertebrae, 
together  with  shortening  of  the  muscle  and  permanent  fixation 
of  the  head. 

A  persistent  tonic  torticollis  should  always  suggest  a  local 
disease,  e.  g.,  one  involving  the  cervical  vertebrae  or  the  brain, 
such  as  a  tumor  or  a  diseased  condition  of  the  neck,  etc. 


SPASMODIC    TORTICOLLIS  529 

Treatment. — A  careful  examination  should  be  made  to  dis- 
cover the  cause  of  the  affection,  and  if  it  is  found,  it  should  be 
treated.  If  the  cause  cannot  be  ascertained,  the  general  health 
of  the  patient  should  be  improved  by  diet,  tonics,  hydrotherapy, 
massage,  etc.  He  should  lead  a  life  free  from  excitement,  and 
follow  an  occupation  that  does  not  fatigue  or  unduly  expose  him 
to  observation.  Various  forms  of  sedatives,  such  as  the  bromids, 
tincture  of  gelsemium,  valerianate  of  zinc,  asafetida,  cannabis 
indica,  etc.,  may  be  of  benefit  in  relieving  the  spasmodic  move- 
ments. Sometimes  tincture  of  belladonna  given  in  increasing 
doses  to  the  physiologic  limit  may  be  followed  by  improvement. 
In  more  severe  cases  morphin,  given  hypodermically,  is  occasion- 
ally recommended.  This  drug  must  not,  of  course,  be  used 
unless  it  is  absolutely  necessary.  Attempts  to  strengthen  the 
opposing  muscles  by  means  of  massage,  systematic  exercise, 
and  electricity  may  be  of  benefit.  Electricity,  as  a  rule,  has  not 
given  much  satisfaction,  but  it  may  be  tried.  It  is  advisable  to 
use  the  galvanic  current,  with  the  positive  pole  over  the  spinal 
accessory  nerve  and  the  negative  pole  at  some  indifferent  point. 
Counterirritation  by  means  of  a  plaster  or  the  actual  cautery 
along  the  back  of  the  neck  has  in  some  cases  proved  beneficial. 
The  application  of  mechanical  supports,  either  in  the  form  of  a 
collar  (a  ring  around  the  head  fixed  to  a  rod,  which  may  be 
attached  to  the  body  or  to  the  neck)  or  a  pad  that  produces 
pressure  upon  a  pressure-point,  if  one  is  present,  may  be  followed 
by  improvement. 

Operative  treatment  of  this  condition  has  in  some  cases 
resulted  in  a  temporary  improvement.  Careful  consideration 
of  the  final  result  obtained  in  many  cases  leads  me  to  the  opinion 
that  operative  interference  is  not  justifiable,  since  the  final 
result  is  not  good,  and  some  cases  have  been  rendered  consider- 
ably worse. 

Some  authorities  have  found  psychotherapy  of  benefit  in  this 
condition. 


34 


530  MANUAL   OF   NERVOUS   DISEASES 

SPASMODIC    AFFECTIONS    OF    THE    MUSCLES    OF 
THE   TRUNK   AND   EXTREMITIES 

These  affections  occur  very  infrequently,  and  then  only  as  the 
result  of  organic  disease  of  the  brain  or  spinal  cord  or  following 
their  overuse  in  certain  occupations.  The  spasms  may  affect 
either  single  muscles  or  groups  of  muscles,  and  may  be  tonic  or 
clonic.  They  may  involve  the  muscles  of  the  upper  extremities, 
of  the  lower  extremities,  of  the  diaphragm,  of  the  trunk,  of  the 
pelvis,  etc.  When  the  spasms  affect  the  muscles  attached  to  the 
pelvis,  they  cause  peculiar  postures  on  standing  and  a  very 
irregular  gait.  In  extreme  cases  they  bring  about  a  tendency 
to  walk  on  all  four  extremities,  a  condition  that  has  been  described 
under  the  title  of  "tortipelvis"  and  "dysbasia  lordotica."  In 
this  condition  the  deformity  is  persistent,  and  consists  of  a 
marked  lordosis  of  the  dorsal  lumbar  region,  the  muscle  twitch- 
ings  being  evident  on  walking  or  standing,  but  not  while  the 
patient  is  in  the  recumbent  position.  The  spasmodic  move- 
ments also  often  affect  the  upper  extremities. 

A  careful  examination  in  all  these  cases  of  spasmodic  neuroses 
fails  to  reveal  the  presence  of  paralysis,  sensory  disturbance,  etc., 
and  we  must,  at  least  at  the  present  time,  acknowledge  our 
inability  to  point  out  organic  pathologic  changes  in  any  portion 
of  the  body,  and  also  we  must  admit  that  mental  treatment  in 
some  cases  has  brought  about  relief  or  cure. 

TIC    (HABIT   SPASM) 

Tics  are  movements  that  can  be  reproduced  voluntarily. 
At  first  the  movements  are  produced  for  some  definite  reason, 
and  by  their  constant  repetition  a  habit  is  formed,  until  they  are 
finally  reproduced  unconsciously,  involuntarily,  and  without 
apparent  cause.  These  movements  may  increase  in  intensity 
and  in  frequency  and  be  associated  with  other  acts. 

Tics  can  be  controlled,  at  least  temporarily,  for  a  short  time, 
but  this  usually  causes  a  sense  of  distress  and  anxiety.  As  soon 
as  the  movements  are  allowed  to  go  on  the  individual  feels  a 
distinct  sense  of  relief.  In  some  cases  the  movements  are 
preceded  by  an  unrest  and  by  a  feeling  as  if  they  must  occur. 


TIC  (habit  spasm)  531 

The  spasms  cease  during  sleep  and  when  the  mind  is  strongly 
diverted  in  another  direction. 

Etiology. — The  disease  occurs  more  frequently  in  children 
between  the  ages  of  sLx  and  thirteen.  As  a  rule,  there  is  a 
neuropathic  tendency.  The  child  may  acquire  these  tics  as  the 
result  of  imitation  or  they  may  first  be  performed  to  relieve  some 
physical  discomfort.  They  have  been  known  to  develop  from 
some  slight  irritation  in  the  nose,  eyes,  mouth,  or  any  other 
portion  of  the  body,  and  to  follow  fright.  Sometimes  these 
habit  movements  develop  without  cause.  Thus  children  whose 
hair  is  long  may  shake  their  heads  backward  and  to  the  side  in 
order  to  throw  the  hair  out  of  the  face;  this  movement  may  be 
continued  even  after  the  hair  has  been  cut.  Those  who  wear 
badly  fitting  clothes  may,  first  as  the  result  of  discomfort,  go 
through  movements  to  adjust  their  clothing  more  comfortably; 
these  movements  may  be  continued  even  in  the  absence  of  the 
exciting  cause,  etc.  In  some  cases  these  habit  movements  occur 
in  epidemic  forms,  many  individuals  becoming  affected.  Al- 
though tic  develops  more  frequently  in  childhood,  yet  it  is  often 
present  in  adults. 

Pathology. — A  most  careful  examination  fails  to  reveal  the 
presence  of  any  organic  pathologic  change.  In  this  disease  the 
acts  that  are  performed  and  that  are  abnormal  under  the  cir- 
cumstances correspond  to  normal  activities  under  proper 
conditions;  consequently  one  would  not  expect  to  find  organic 
disturbances.  The  conditions  under  which  these  acts  occur  are 
the  result  of  a  deficient  psychic  inhibition  which  allows  purposive 
activities  to  take  place  without  either  adequate  reflex  stimulation 
or  adequate  external,  defensive,  or  volitional  requirement. 

Symptoms. — ^Any  volitional  act  that  is  produced  at  first  for 
some  definite  purpose,  in  imitation  of  the  acts  of  others,  or 
thoughtlessly,  may,  by  constant  repetition,  become  habitual 
and  be  reproduced  unconsciously.  The  tic  may  consist  of  a 
single  movement  or  of  a  number  of  movements,  or  may  be  gen- 
eral. The  movements  may  occur  occasionally,  frequently, 
and  sometimes  almost  constantly.  In  many  cases  the  effort  to 
overcome  these  movements  is  accompanied  by  marked  mental 
distress,  and  great  relief  is  felt  when  they  are  allowed  to  occur. 


532  MANUAL   OF   NERVOUS   DISEASES 

The  tic  may  involve  the  eyelids,  giving  rise  to  winking  of 
one  or  both  lids;  this  may  or  may  not  be  accompanied  by  wrink- 
ling of  the  forehead,  and  may  involve  the  face,  causing  grimaces 
to  be  made;  these  may  be  bilateral  or  unilateral.  The  head  may 
be  shaken  from  side  to  side  as  if  to  toss  the  hair  from  before  the 
eyes;  movements  of  the  lips  and  tongue  may  take  place,  giving 
rise  to  sucking,  sniffing,  pouting,  biting,  gulping,  etc.  The 
shoulders  and  arms  may  be  affected,  causing  shrugging  move- 
ments, the  arms  being  thrown  from  side  to  side,  snapping  of  the 
fingers,  etc.  The  trunk  may  be  affected,  giving  rise  to  peculiar 
movements ;  or  the  lower  extremities  may  be  involved,  giving  rise 
to  peculiarities  of  gait,  etc.  Tics  of  speech  may  occur  in  which 
the  individual  repeats  words,  or  he  may  skip  certain  words  in  a 
sentence,  etc. 

Distraction  and  occupation,  as  a  rule,  have  a  soothing  effect 
upon  the  tics,  and  excitement,  emotional  disturbance,  observa- 
tion, etc.,  tend  to  increase  them. 

Course. — The  onset  of  this  condition  is  usually  slow.  It 
frequently  follows  anxiety  or  some  emotional  disturbance.  In 
childhood  the  onset  may  occur  as  the  result  of  imitation,  re- 
flex irritation,  discomfort,  emotional  disturbance,  etc.  The 
condition  runs  a  chronic  course,  marked  by  remissions  and  in- 
termissions. In  a  few  cases  there  is  a  gradual  extension  of 
the  tic  from  one  part  of  the  body  to  the  other,  and  eventually 
mental  failure  occurs. 

Prognosis. — Tic  beginning  in  early  life  usually  presents  a 
good  prognosis  when  the  child  can  be  placed  under  favorable 
conditions  for  treatment.  In  adults  the  prognosis  is  not  so 
good,  intermissions  being  frequently  followed  by  recurrences. 

Diagnosis. — The  diagnosis  is  made  from  the  fact  that  the 
movements  that  occur  can  be  voluntarily  reproduced;  that 
these  movements  occur  without  the  patient  being  conscious  of 
them;  that  they  are  automatic;  that  the  efforts  to  restrain  them 
cause  distress,  and  that  relief  occurs  when  they  are  allowed  to 
recur. 

This  disease  must  be  differentiated  from  hysteria,  in  which 
condition  the  movements  come  on  suddenly  and  are  associated 
with  other  evidences  of  hysteria.     From  chorea  this  disease  is 


CHOREA  533 

distinguished  by  the  fact  that  in  chorea  the  movements  are 
purposeless,  occurring  almost  constantly,  and  are  rendered 
worse  when  an  effort  is  made  to  restrain  them,  whereas  in  tic 
the  movements  are  purposive,  frequently  lengthy  intervals 
occur  between  the  movements,  and  occupation  has  a  soothing 
effect;  also  they  can  be  voluntarily  repressed.  It  is  well  to 
remember  that  in  some  cases  of  dementia  prcecox  peculiar 
purposive  movements  of  the  face  and  body  occur. 

Treatment. — In  those  cases  which  occur  in  children  as  the 
result  of  discomfort  or  of  reflex  irritation  the  exciting  cause 
should,  if  possible,  be  removed.  In  all  cases  the  physical  con- 
dition of  the  patient  should  receive  attention.  In  some  cases 
it  is  necessary  to  isolate  the  patient  from  his  family  and  friends. 
For  the  cure  of  the  tic  it  is  necessary  to  reestablish  self-control; 
this  is  done  by  reeducation,  the  individual '  endeavoring  volun- 
tarily to  control  and  prevent  the  occurrence  of  the  spasm.  He 
should  go  through  a  regular  exercise  before  a  mirror  several 
times  a  day,  voluntarily  contracting  the  muscles  which  are 
affected  and  also  their  opponents;  this  treatment  is  best  carried 
on  in  the  presence  of  some  one  who  has  control  of  the  patient. 
In  children  rewards  may  be  given  for  successful  efforts  to  control 
the  affection.  Harsh  treatment  and  punishment  usually  tend 
to  aggravate  the  affection.-  Hydrotherapy  and  generally  gym- 
nastic exercises  are  also  of  benefit,  in  so  far  that  they  improve 
the  individual's  general  condition  and  seem  to  exert  a  soothing 
effect  upon  the  patient. 

Anemic  and  debilitated  individuals  should  be  given  tonics, 
and  those  of  a  nervous,  restless  temperament  may  be  given 
sedatives. 

CHOREA 

Chorea  is  a  term  derived  from  the  Greek  word  '/opeta,  mean- 
ing to  dance.  Under  this  term  are  grouped  a  number  of  con- 
ditions that  exhibit  as  their  characteristic  symptom  involuntary, 
uncontrollable,  unexpected,  and  purposeless  contractions  of 
muscles  or  of  groups  of  muscles. 

Under  this  head  are  included  chorea  minor,  Sydenham's 
chorea  or  St.  Vitus'  dance;  Huntington's  chorea,  or  chronic 


534  MANUAL   OF   NERVOUS   DISEASES 

hereditary  chorea ;  chronic  progressive  chorea  of  adults ;  chorea 
accompanying  organic  brain  lesions;  senile  chorea;  chorea 
insaniens;  electric  chorea,  and  Dubini's  chorea.  These  con- 
ditions may  be  divided  into  several  groups,  which  present  a 
similarity  of  motor  symptoms,  but  which  should  be  correctly 
differentiated  one  from  the  other. 

For  purposes  of  description  these  conditions  will  be  divided 
into  four  groups:  Group  i  includes  those  forms  of  chorea  that 
are  probably  due  to  an  acute  infectious  or  toxic  condition, 
chorea  minor,  or  Sydenham's  chorea,  and  chorea  insaniens; 
Group  2  includes  senile  chorea,  chorea  accompanying  organic 
brain  lesions,  chronic  progressive  chorea  of  adults,  and  Hunting- 
ton's or  hereditary  chorea;  these  choreas  are  due  to  a  progressive 
organic  degenerative  cerebrospinal  disease  of  unknown  origin; 
Group  3  includes  epidemic  chorea,  which  is  due  to  imitation, 
and  is  a  form  of  hysteria;  Group  4  includes  electric  chorea  and 
Dubini's  chorea. 

CHOREA   MINOR,    SYDENHAM'S   CHOREA   OR  ST.  VITUS' 
DANCE,    AND    CHOREA   INSANIENS 

Taken  collectively,  this  group  may  be  regarded  as  a  disease 
of  the  central  nervous  system,  brain,  medulla,  and  spinal  cord, 
caused  by  the  action  of  toxins,  which  give  rise  to  mental  and 
motor  manifestations  of  an  irritative  nature,  and  which  may 
run  an  acute,  a  subacute,  or  a  chronic  course,  either  with  or 
without  remissions. 

Etiology. — ^The  affections  classified  under  this  group  occur 
most  frequently  between  the  ages  of  six  and  fourteen,  although 
no  age  is  exempt.  The  disease  is  frequently  seen  in  children 
under  six  years  of  age,  and  also  after  the  fourteenth  year. 
Chorea  insaniens  occurs  with  special  frequency  in  women 
during  pregnancy.  The  proportion  of  females  to  males  that 
are  affected  is  about  3  to  i.  A  large  majority  of  the  in- 
dividuals affected  are  found  among  the  children  of  the  classes 
who  live  amid  unhygienic  surroundings,  who  are  poorly  fed,  and 
who  dw^ell  in  poorly  ventilated  houses. 

A  nervous  temperament,  anemia,  overwork,  fright,  trauma. 


CHOREA    MINOR,    SYDENHAM'S    CHOREA  535 

pregnancy,  affections  of  the  throat  and  nose,  rheumatic  condi- 
tions, etc.,  are  among  the  frequent  predisposing  conditions. 
This  disease  sometimes  follows  the  infectious  diseases,  such  as 
scarlet  fever,  influenza,  diphtheria,  t}^hoid,  etc. 

The  disease  occurs  more  frequently  in  the  early  spring  and 
early  summer  than  at  other  periods  of  the  year.  In  many  cases 
one  attack  predisposes  to  another,  and  in  a  large  number  of 
cases  relapses  are  prone  to  occur. 

Pathology. — Pathologic  examinations  are  rarely  made  in 
cases  of  acute  chorea,  but  in  practically  all  reported  cases  a 
dilatation  of  the  capillaries  in  the  nervous  system  was  discovered. 
Punctiform  hemorrhages,  perivascular  infiltration,  softening, 
and  granular  degeneration  of  the  cells  in  the  gray  matter  of  the 
cortex,  in  the  basilar  ganglia,  medulla,  and  the  cord  were  also 
seen,  and  in  some  places  thickening  of  the  meninges  was  present. 
These  pathologic  findings  simulate  the  characteristic  appearance 
of  the  nervous  system  in  the  chronic  toxemias. 

Upon  taking  into  consideration  the  various  causative  factors 
of  this  disease,  one  is  forced  to  the  conclusion  that  there  is  no 
specific  toxin,  nor  does  the  toxic  substance  alw^ays  originate  in 
a  similar  manner.  Undoubtedly,  a  group  of  cases  are  seen  in 
which  the  toxin  is  of  bacterial  origin. 

In  a  large  proportion  of  cases  chorea  develops  along  with 
or  follows  rheumatic  manifestations^  with  or  without  true 
endocardial  involvement.  In  these  cases  diseases  of  the  nose 
and  throat  are  commonly  present.  From  a  careful  considera- 
tion of  a  number  of  cases  as  to  development,  course,  and  results 
of  treatment,  I  am  firmly  convinced  that  certainly  40  per  cent, 
of  the  acute  choreas  are  caused  by  the  absorption  of  toxic 
substances  which  are  formed  as  the  result  of  bacterial  activity, 
and  that  organisms  gain  entrance  into  the  system  through  the 
structures  in  the  pharynx,  the  nose,  or  the  nasopharynx. 

Still  another  group  of  cases  are  seen  in  which  local  disease  can 
be  absolutely  excluded,  and  w^hich  run  their  course  without 
temperature;  these  cases  follow^  fright,  shock,  and  worry.  It  is 
my  opinion  that  in  this  group  of  cases  toxic  substances  form  in 
neurotic  individuals  as  the  result  of  perversion  of  bodily  metabo- 
lism.   Chorea  occurring  during  and  after  pregnancy  may  be  due 


536  MANUAL   OF   NERVOUS   DISEASES 

to  the  formation  of  a  toxic  substance  as  the  result  of  perverted 
metabolism,  or  may  follow  an  infection. 

In  many  cases  a  combination  of  these  factors  certainly  exists, 
as  where  the  individual  lives  under  unfavorable  hygienic  con- 
ditions, has  insufficient  food,  and  is  subject  to  mental  stress  or 
strain ;  in  these  cases  toxins  may  be  formed  due  to  perversion  of 
metabolism,  and  the  general  resistance  of  the  individuals  is 
lowered.  This  state  predisposes  to  the  entrance  of  pathologic 
organisms  into  the  system. 

Portions  of  the  Nervous  System  Involved. — Many  of  the  symp- 
toms, such  as  restlessness,  depression,  irritability,  weakness  of 
memory,  excitement,  etc.,  are  due  to  the  action  of  a  toxic  sub- 
stance on  the  cerebral  cortex.  The  motor  manifestations  cannot 
be  directly  caused  by  the  irritation  of  the  cerebral  cells,  for  the 
movements  consist  of  irregular,  uncontrollable,  inimitable,  un- 
expected, and  purposeless  contractions  of  muscles  or  groups  of 
muscles.  These  movements  are  not  characteristic  of  cortical 
activity,  since  the  latter  always  brings  about  purposeful  acts, 
whereas  a  consideration  of  the  relation  of  the  grouping  of  cells  in 
the  spinal  cord,  with  the  segmental  connection  of  these  groups 
to  the  various  muscles  of  the  extremities  and  trunk,  makes  it 
clear  how  irritation  of  the  cells  or  groups  of  cells  in  the  anterior 
horns  can  bring  about  the  characteristic  movements  of  chorea. 
Moreover,  in  many  cases  of  chorea  the  reflexes  are  abolished 
or  markedly  decreased,  and  this  could  take  place  only  as  the 
result  of  spinal  cord  or  peripheral  nerve  involvement.  In  many 
cases  the  respiratory  rhythm  is  interfered  with,  peculiar  move- 
ments occur  about  the  face,  strange  sounds  are  made,  speech  is 
impaired,  etc.  These  symptoms  clearly  point  to  involvement 
of  the  medulla.  It  would,  therefore,  appear  to  me  that  in  chorea 
there  is  an  involvement  of  the  brain,  medulla,  and  spinal  cord. 

Symptoms. — Abnormality  of  movement  and  mental  peculiar- 
ities are  the  two  principal  manifestations  of  this  disease. 

Motor  Symptoms. — At  first  more  or  less  motor  restlessness 
may  be  present,  the  individual  being  unable  to  remain  still  for 
any  length  of  time;  or  the  movements  become  awkward,  and 
there  is  a  tendency  to  drop  things.  Later  on,  or  even  from  the 
onset,  peculiar  spasmodic  movements  occur;  these  movements 


CHOREA   MINOR,    SYDENHAM'S    CHOREA  537 

are  unexpected  and  inimitable;  they  may  be  very  slight,  and 
only  interfere  with  complicated  acts,  and  not  be  noticeable  when 
at  rest,  or  they  may  be  more  marked,  every  movement  involv- 
ing fine  coordination  becoming  impossible.  These  movements 
cannot  be  arrested  by  the  will  for  any  length  of  time,  and  are 
increased  by  attention  and  by  excitement.  The  movements 
may  be  slight  and  of  only  momentary  duration,  but  in  some 
cases  they  become  more  or  less  general,  and  may  be  violent  and 
continuous. 

These  abnormalities  of  movement  more  commonly  affect  the 
face  and  the  extremities;  in  many  cases  irregularities  in  the 
respiratory  rate  can  be  noticed. 

When  the  movements  affect  the  upper  extremities,  abduction 
or  adduction  of  the  arm  occurs,  together  with  peculiar  move- 
ments of  the  shoulder;  the  fingers  are  spread  out,  flexed,  and 
extended.  When  the  face  is  involved  the  forehead  becomes 
wrinkled,  the  mouth  drawn  to  one  side,  and  the  individual 
makes  queer  grimaces;  the  cheeks  twitch,  the  movements  of  the 
tongue  are  irregular,  unexpected  movements  of  the  eyes  and 
eyelids  occur,  and  the  head  is  thrown  from  side  to  side.  The 
trunk  may  be  rotated.  When  the  laryngeal  and  respiratory 
muscles  are  affected  peculiar  noises  are  made,  or  peculiar  sounds 
may  be  uttered.  Sometimes  inability  to  swallow  develops.  The 
legs  are  also  frequently  affected,  and  walking  is  interfered  with; 
the  patient  may  stagger,  or  the  gait  become  jerky  and  uncertain. 
It  is  only  in  very  severe  cases  that  walking  becomes  impossible. 
Weakness  in  the  affected  muscles  may  occasionally  be  marked, 
but  complete  or  permanent  paralysis  does  not  occur. 

The  involuntary  movements  are  not  limited  to  one  group  of 
muscles,  but  occur  at  irregular  intervals  in  the  different  groups. 
Both  the  distribution  and  the  occurrence  are  characterized  by 
this  irregularity — the  movements  which  are  purposeless  con- 
stantly vary  in  form  and  in  direction.  Awkwardness  of  move- 
ment is  always  present. 

There  is  practically  no  disturbance  of  sensation.  The  tendon- 
reflexes  may  be  normal,  increased,  or  absent;  ataxia  may  occur, 
and  in  some  cases  is  a  very  prominent  symptom.  One  side  of 
the  body  may  be  affected  to  a  much  greater  extent  than  the 


538  MANUAL   OF   NERVOUS   DISEASES 

opposite  side,  and  in  some  instances  the  symptoms  are  limited 
practically  to  one  side  of  the  body,  this  condition  being  known  as 
hemichorea.  In  many  of"the  more  severe  cases  difficulty  in 
talking  develops  and  speech  sometimes  becomes  impossible. 
In  severe  cases  more  or  less  constant  violent  movements  take 
place,  and  the  individual  is  never  still;  he  may  frequently  injure 
himself  by  coming  in  contact  with  furniture  or  other  objects, 
and  great  exhaustion  results. 

As  a  rule,  the  movements  cease  during  sleep  and  are  increased 
by  voluntary  movement. 

Mental  Symptoms. — These  patients  are  usually  very  emo- 
tional, laughing  or  weeping  being  easily  provoked.  Earlier  in 
the  disease  there  is  marked  irritability,  and  this  often  causes  the 
individual  to  be  regarded  as  disagreeable  and  cross  until  the 
nature  of  the  malady  is  discovered.  The  patient's  disposition 
generally  undergoes  a  change,  and  he  becomes  cross,  quarrel- 
some, depressed,  and  unable  to  exercise  self-control.  In  some 
cases  the  mind  seems  to  become  weak.  Emotional  excitement 
usually  increases  the  movements.  In  many  cases  there  is 
difficulty  in  fixing  the  attention,  and  disturbance  of  memory 
is  also  present. 

In  adults,  but  rarely  in  children,  there  may  develop  a  marked 
depression  or  delirium,  sometimes  accompanied  by  acute 
maniacal  excitement,  confusion,  and  hallucinations  or  delusions. 
This  marked  mental  state  generally  develops  at  the  height  of 
the  disease,  giving  rise  to  what  is  known- as  chorea  insaniens. 
The  most  severe  types  occur  during  pregnancy,  in  the  puerperal 
state,  and  in  general  infections. 

Paralytic  Chorea. — There  is  one  type  of  chorea  in  which,  in- 
stead of  the  marked  abnormality  of  movement,  an  apparent  pare- 
sis of  apart  or  of  the  entire  body  occurs.  It  is  first  noticed  that 
the  individual  uses  one  side  of  the  body  less  frequently  than  the 
other,  or  avoids  using  one  side  altogether.  This  motor  involve- 
ment extends  and  may  involve  the  entire  body.  The  movements 
of  the  limbs  or  body  may  still  be  performed,  but  only  in  a  very 
feeble  way;  the  muscles  become  flaccid,  and  the  tendon  reflexes 
are  decreased  or  abolished.  Transient  tingling  develops,  which 
becomes  more  marked  during  the  course  of  the  disease.     When 


CHOREA   MINOR,    SYDENHAM  S    CHOREA  539 

the  pseudoparalysis  affects  the  muscles  of  articulation,  mutism 
develops.  This  form  of  chorea  is  known  as  paralytic  chorea. 
Its  course  differs  from  the  ordinary  type  of  chorea  only  in  the 
onset,  choreic  movements  developing  during  the  course  of  the 
disease,  revealing  its  true  nature.  Muscular  atrophy  does  not 
occur. 

The  general  condition  of  the  patient  depends  to  a  great  extent 
upon  the  severity  of  the  movements,  the  amount  of  rest  the 
patient  gets,  his  ability  to  take  nourishment,  and  upon  the 
complications  which  may  be  present.  Among  the  last  may  be 
mentioned  endocarditis,  articular  rheumatism,  pyrexia,  etc. 
Individuals  suffering  with  chorea  are  usually  pale  and  badly 
nourished,  have  little  appetite,  and  are  constipated.  In  about 
40  per  cent,  of  cases  heart  murmurs  are  present;  these  may  be 
functional,  hemic,  or  due  to  endocarditis.  Fever  and  accelera- 
tion of  the  pulse-rate  are  present  in  many  cases. 

Course. — The  onset  of  this  disease  is  usually  gradual,  but  in 
some  cases  it  may  appear  suddenly,  as  after  fright  or  following 
mental  strain.  In  mild  cases  the  movements  may  be  so  slight 
as  to  be  detected  only  upon  careful  examination,  the  mental  and 
emotional  symptoms  being  more  prominent;  in  other  cases 
there  is  a  gradual  increase  in  the  motor  symptoms,  which  may 
become  so  severe  or  so  constant  as  to  interfere  with  the  patient's 
rest  or  with  his  ability  to  take  nourishment.  In  some  cases  the 
movements  are  so  violent  that  the  patient  must  be  surrounded  by 
mattresses  or  similar  soft  articles  in  order  to  prevent  him  from 
severely  injuring  himself.  In  most  cases  the  mental  s}Tnptoms 
never  reach  an  alarming  degree  of  severity,  but  when  the  chorea 
develops  in  adults,  and  especially  in  pregnant  women  or  in  neu- 
rotic subjects,  or  if  it  follows  a  severe  infection,  marked  men- 
tal symptoms  may  occur.  In  the  milder  cases  the  usual  dura- 
tion is  about  five  weeks;  the  severer  cases  last  from  five  weeks 
to  a  year,  and  some  cases  last  for  a  very  prolonged  period.  In 
the  majority  of  cases  occurring  in  children  the  duration  is  about 
ten  weeks,  the  onset  being  gradual,  and  the  condition  subsiding 
gradually. 

Prognosis, — ^The  prognosis  as  to  life  and  as  to  recovery  is  in 
nearly  all  cases  good.      Death  occurs  only  in  the  exceedingly 


540  MANUAL   OF   NERVOUS   DISEASES 

severe  forms,  in  which  muscular  contractions  are  so  severe  as  to 
make  sleep  and  nutrition  impossible ;  in  these  cases  death  is  due 
to  exhaustion  or  to  cardiac  degeneration.  Death  may  also  occur 
as  the  result  of  injuries.  Organic  cardiac  affections  occurring 
in  very  young  individuals  do  not  seem  to  affect  the  prognosis. 
When  this  condition  exists  in  older  individuals  the  prognosis 
as  to  life  is  more  serious. 

Rapid  emaciation,  delirium,  and  a  rise  of  temperature  occur- 
ring during  the  course  of  chorea  are  serious  signs.  Chorea 
occurring  during  pregnancy  or  cases  in  which  there  are  marked 
mental  manifestations  present  a  more  serious  prognosis.  In 
adults  a  form  of  chorea  may  occur  that  runs  a  chronic  course 
and  lasts  for  years  or  during  the  entire  lifetime. 

Chorea  shows  a  marked  tendency  to  recur,  the  intervals 
between  attacks  usually  lasting  about  a  year.  In  some  cases, 
however,  attacks  may  follow  one  another  in  quick  succession; 
in  others  several  years  may  intervene  between  attacks.  Gen- 
erally not  more  than  one  or  two  relapses  occur,  but  a  greater 
number  have  been  observed.  The  older  the  patient,  the  more 
likely  is  the  disease  to  run  a  protracted  course,  but  this  does  not 
preclude  the  hope  of  recovery. 

Diagnosis. — The  diagnosis  of  this  disease  is  usually  very 
easily  made.  Some  difficulty  may  be  experienced  in  distinguish- 
ing a  chorea  that  begins  with  weakness  from  a  paralytic  condition, 
but  a  careful  study  of  the  case  will  reveal  the  muscular  twitch- 
ings  and  the  characteristic  mental  state  which  will  enable  one 
to  reach  a  correct  diagnosis. 

Chorea  may  be  mistaken  for  general  tic,  or  in  those  cases  in 
which  the  choreic  movements  are  limited  to  certain  parts  of  the 
body  or  to  the  face  it  may  be  mistaken  for  localized  tic;  the 
differentiation  is  made  from  the  fact  that  the  movements  in 
tic  are  purposive  and  can  be  reproduced  voluntarily,  whereas 
in  chorea  the  movements  are  purposeless  and  cannot  be  imitated; 
moreover,  in  tic  the  mental  state  is  normal,  whereas  in  chorea 
the  individual  is  emotional  and  irritable.  Temperature,  pulse, 
and  cardiac  disturbances  are  frequently  present  in  chorea, 
whereas  they  are  generally  absent  in  tic. 

Chorea  occurring  in  adults  must  be  differentiated  from  Hun- 


CHOREA    MINOR,    SYDENHAM'S    CHOREA  54 1 

tington's  chorea,  senile  chorea,  chorea  accompanying  organic 
brain  lesions,  etc.  From  Huntington^s  chorea  it  is  differentiated 
by  the  history  of  the  case  and  by  a  consideration  of  the  progress 
of  the  disease:  in  Huntington's  chorea  the  disease  usually  mani- 
fests itself  for  the  first  time  at  about  the  fortieth  year,  the  abnor- 
mal movements  commonly  beginning  in  the  hands,  and  gradually 
extending  until  the  entire  body  is  affected;  the  mental  symptoms 
develop  gradually  and  finally  lead  to  dementia.  From  senile 
chorea  the  condition  is  differentiated  by  the  age  of  the  patient, 
by  the  prominence  of  the  mental  disturbances,  and  by  the  fact 
that  the  choreic  movements  are  usually  accompanied  by  more  or 
less  generalized  tremors.  From  chorea  accompanying  organic 
cerebral  disease  this  condition  is  differentiated  by  the  history  of 
the  symptoms  following  some  organic  neural  disease,  by  the 
presence  of  the  symptoms  of  that  disease,  and  by  the  fact  that 
the  choreic  movements  are  usually  limited  to  the  portions  of  the 
body  that  are  under  control  of  that  portion  of  the  central 
nervous  system  that  is  organically  affected. 

Treatment. — The  patient's  room  should  be  light,  well  venti- 
lated, and  quiet.  Older  children  and  adults  should  be  confined 
to  bed,  and  for  younger  children  as  much  rest  as  possible  should 
be  insisted  upon.  The  patient  should  be  isolated,  only  one 
or  two  persons  being  in  attendance.  The  diet  should  be  light 
and  nutritious,  and  the  patient  should  be  encouraged  to  drink 
an  abundance  of  water.  The  bowels  should  be  kept  w^ell  open, 
and  a  daily  warm  bath  is  to  be  given.  Gentle  massage  is  often 
beneficial.  In  those  cases  in  which  the  movements  are  at  all 
violent  or  severe  the  patient  should  be  kept  in  a  bed  that  is  well 
padded  and  be  carefully  watched  day  and  night  so  that  he  does 
not  injure  himself.  In  the  case  of  adults  in  whom  marked 
mental  symptoms  develop  it  may  be  necessar}^  to  remove  the 
patient  to  an  institution  so  that  he  may  be  cared  for  properly. 

The  cause  of  the  condition  should  be  carefully  sought,  and 
if  found  it  should  be  treated  and,  if  possible,  removed.  In  those 
cases  in  which  diseased  conditions  of  the  throat  and  nose  exist 
proper  medical  and  surgical  treatment  should  be  instituted. 
It  has  been  my  experience  that  in  many  cases  proper  treatment 
directed  toward  the  throat  and  nose  has  tended  to  shorten  the 


542          '  MANUAL   OF   NERVOUS   DISEASES 

duration  of  the  disease,  and  has  cured  cases  that  had  existed 
with  slight  remissions  for  a  number  of  years;  such  treatment  has 
also  tended  to  prevent  relapses  and  recurrences. 

When  chorea  occurs  in  pregnant  women,  it  may  be  necessary 
to  terminate  the  pregnancy  in  order  to  save  the  patient's  life; 
this  measure  should  be  resorted  to  only  Vv^hen  there  is  a  condition 
of  extreme  exhaustion,  or  in  the  presence  of  organic  heart 
disease,  marked  mental  manifestations,  etc.  In  all  cases  the 
bowels  should  be  freely  opened  by  the  administration  of  calomel, 
followed  by  castor  oil  or  a  saline  purgative.  In  those  cases  in 
which  a  rheumatic  tendency  is  present  or  in  which  a  rise  of 
temperature  and  cardiac  involvement  occur,  sodium  salicylate, 
aspirin,  salicin,  etc.,  in  doses  oppropriate  to  the  age,  should  be 
given  every  three  or  four  hours.  Antiseptic  nose  and  throat 
sprays  should  also  be  used.  Patients  who  are  pale  and  debilitated 
should  receive  arsenic,  preferably  in  the  form  of  Fowler's  solu- 
tion; this  should  be  given  three  times  a  day  in  increasing  doses, 
beginning  with  three  drops  and  increasing  the  dose  until  the 
physiologic  limit  of  the  arsenic  is  reached,  which  is  manifested 
by  pufi&ness  of  the  eyelids,  etc.  Arsenous  acid,  combined  w^ith 
iron,  or  subcutaneous  injections  of  cacodylic  acid,  in  doses  of 
from  3  to  §  grain,  may  also  be  used. 

If  the  arsenic  cannot  be  taken  without  discomfort,  or  if  it 
gives  rise  to  disagreeable  symptoms,  its  use  should  be  discon- 
tinued, and  in  its  stead  the  iron  preparations  may  be  admin- 
istered; for  children  the  syrup  of  the  iodid  of  iron,  in  doses  rang- 
ing from  ID  to  30  drops  three  times  a  day,  is  very  efficacious. 

If  malarial  infection  is  suspected,  quinin  should  be  given. 
When  the  movements  are  extensive  and  persistent,  or  when 
restlessness  is  marked,  the  bromids  exert  a  soothing  effect;  in 
some  cases  in  which  these  fail  better  results  are  obtained  from 
chloral  or  from  a  combination  of  bromid  and  chloral.  In  very 
severe  cases  it  may  be  necessary  to  use  chloroform.  Veronal, 
medinal,  adalene,  etc.,  are  all  of  service  in  inducing  sleep. 

Cardiac  involvement,  which  is  one  of  the  most  frequent 
complications,  is  best  treated  by  rest  in  bed,  stimulation,  if 
necessary,  with  caffein,  and  the  application  of  ice-caps  to  the 
precordial  region. 


HUNTINGTON  S    CHOREA  543 

For  a  considerable  period  after  the  attack  these  patients 
should  avoid  excitement  and  overexertion.  Tonics  and,  if 
possible,  a  change  of  climate  for  a  time  should  be  ordered. 


HUNTINGTON'S  CHOREA  (CHRONIC  PROGRESSIVE 
HEREDITARY   CHOREA) 

Etiology. — This  is  a  somewhat  uncommon  disease,  which  is 
transmittied  from  one  generation  to  another.  It  was  first 
described  by  Dr.  Huntington,  of  East  Hampton,  Long  Island. 
The  disease  may  skip  a  generation,  or  other  forms  of  ner\^ous 
disease,  such  as  epilepsy,  hysteria,  etc.,  may  occur  in  its  stead. 
Males  are  affected  somewhat  more  frequently  than  females. 
The  disease  generally  appears  between  the  ages  of  twenty  and 
forty,  but  may  develop  earlier  or  later.  When  it  is  transmitted 
through  several  generations  it  shows  a  tendency  to  develop 
later  in  life.  In  some  cases  the  disease  appears  gradually  with- 
out an  exciting  cause;  in  others  the  initial  symptoms  follow 
shock,  injury,  emotional  disturbance,  pregnancy,  etc. 

Pathology. — Changes  of  a  sclerotic  nature  affecting  the  me- 
ninges, disseminated  chronic  inflammatory  areas  in  the  cortex 
of  the  motor  region,  changes  in  the  wall  of  the  blood-vessels, 
and  sclerotic  patches  in  the  basal  ganglia  have  all  been  de- 
scribed in  this  condition. 

Symptoms. — A  gradual  restlessness  and  peculiarity  of  move- 
ments, at  first  limited  to  the  upper  extremities,  the  face,  and  the 
neck,  develop.  These  symptoms  gradually  increase  in  severity 
and  in  extent,  until  all  voluntar}^  movements  of  the  body  are 
affected.  These  movements  resemble  those  of  chorea  minor; 
they  are  irregular  and  more  or  less  constant.  The  peculiar 
contractions  which  involve  muscles  or  groups  of  muscles  bring 
about  strange,  inimitable,  and  uncontrollable  movements  of  the 
extremities,  trunk,  face,  neck,  etc.  The  ocular  movements 
are  not  usually  affected.  The  gait  is  uncertain  and  jerky,  and 
at  times  the  individual  is  thrown  to  the  ground.  Speech  is 
interfered  with  by  twitching  of  the  tongue,  and  by  the  move- 
ments of  the  lips  and  the  spasmodic  respiratory  efforts.     The 


544 


MANUAL   OF   NERVOUS   DISEASES 


muscles  of  the  face  contract,  giving  rise  to  grimaces.  All 
these  movements  can  be  suppressed  for  a  time  by  an  effort  of 
the  will,  and  they  generally  cease  during  sleep.  They  become 
more  intense  and  violent  as  the  result  of  mental  or  physical 
exhaustion. 


Fig.  155. — Huntington's  chorea.     Senile  chorea. 

The  motor  power  remains  practically  normal  during  the  entire 
course  of  the  illness.  Hemiplegia  may  develop  in  the  later 
stages  of  the  disease.  There  are  no  disturbances  of  sensation, 
but  the  reflexes  are  usually  slightly  increased.  The  internal 
organs  are  not  affected  (Fig.  155). 

The  movements,  which  are  always  bilateral,  generally  cease 


CHRONIC   PROGRESSIVE    CHOREA    OF    ADULTS  545 

during  sleep.  Gradually,  during  the  course  of  the  disease,  the 
second  characteristic  symptom  develops;  i.  e.,  sl  gradual  pro- 
gressive mental  feebleness.  These  patients  may  be  very  ir- 
ritable from  the  onset,  or,  on  the  other  hand,  a  state  of  indiffer- 
ence may  be  present.  Weakness  of  memory  and  inability  to 
fix  the  attention  gradually  appear,  the  judgment  becomes  de- 
fective, and  the  patient  becomes  very  emotional.  In  some 
cases  marked  psychosis  appears,  the  patient  developing  delusions 
or  hallucinations,  or  he  becomes  excited  or  depressed.  Occa- 
sionally attempts  at  suicide  are  made. 

As  the  disease  progresses  the  mental  weakness  increases,  and 
a  gradual  weakness  and  rigidity  in  the  legs  and  arms  develop. 
Most  cases  must  be  committed  sooner  or  later  to  an  institution. 

Course. — The  course  is  gradually  progressive,  the  condition 
persisting  for  many  years. 

Prognosis. — The  prognosis  is  very  unfavorable,  the  disease 
being  practically  incurable.  The  individual  eventually  succumbs 
to  some  intercurrent  disease  or  as  the  result  of  interference  with 
nutrition,  etc. 

Diagnosis. — ^The  diagnosis  is  made  from  the  hereditary  nature 
of  the  condition,  and  from  the  fact  that  it  develops  usually 
between  the  thirtieth  and  the  fortieth  year ;  also  by  the  develop- 
ment of  mental  symptoms  during  the  course  of  the  disease. 

It  is  differentiated  from  senile  chorea  by  the  fact  that  in  this 
condition  no  hereditary  influence  can  be  traced,  and,  moreover, 
the  disease  develops  later  in  life. 

Treatment  is  purely  symptomatic.  Drugs  do  not  seem 
capable  of  arresting  the  progress  of  the  disease.  The  patient 
should  be  carefully  nourished,  and  when  his  mental  condition 
becomes  so  disturbed  that  it  is  no  longer  possible  to  care  for 
him  properly  in  the  home,  it  is  advisable  to  remove  him  to  an 
institution  properly  equipped  for  the  care  of  the  insane. 

CHRONIC  PROGRESSIVE  CHOREA  OF  ADULTS  AND    SENILE 

CHOREA 

These  forms  of  chorea  usually  occur  between  the  ages  of 
fifty-five  and  eighty.     Males  are  affected  slightly  more  fre- 
35 


546  MANUAL   OF   NERVOUS   DISEASES 

quently  than  females.  A  history  of  a  neuropathic  taint  in  the 
family  is  frequently  obtained. 

Pathology. — The  pathologic  changes  that  take  place  in  this 
condition  are  somewhat  similar  to  those  described  in  Hunting- 
ton's chorea.  There  is  no  satisfactory  explanation  of  the  man- 
ner in  which  these  changes  are  brought  about. 

Symptoms. — The  abnormal  movements  resemble  those  that 
occur  in  other  types  of  chorea.  The  muscles  of  the  upper  ex- 
tremities, neck,  face,  and  tongue  are  those  most  frequently 
affected.  Articulation  and  swallowing  may  be  greatly  interfered 
with.     A  moderate  degree  of  muscular  weakness  may  be  present. 

These  patients  are  very  emotional  and  irritable,  and  in  some 
cases  marked  mental  weakness  develops.  Groups  of  cases  are 
seen  in  which  the  choreic  movements  and  the  mental  w^eakness 
are  progressive.  These  patients  are  distinguished  from  those 
suffering  from  Huntington's  chorea  only  by  the  absence  of  the 
hereditary  history. 

Course. — In  these  cases,  as  in  the  ordinary  types  of  chorea, 
the  movements  are  increased  by  emotional  disturbances,  and 
usually  cease  during  sleep.  They  may  appear  more  or  less 
suddenly  after  shock,  anxiety,  injury,  or  exhausting  conditions. 
They  usually  run  a  slowly  progressive  course. 

Prognosis. — The  abnormal  movements  may  continue  for 
prolonged  periods,  persisting  until  death  takes  place,  which  may 
not  be  hastened  by  the  presence  of  this  condition.  Except  in  a 
very  few  instances  recovery  is  not  to  be  looked  for. 

Diagnosis. — The  diagnosis  is  made  from  the  presence  of  the 
characteristic  movements,  which  cease  during  sleep  and  are 
rendered  worse  by  emotional  excitement  and  on  observation. 

Chronic  progressive  chorea  of  adults  is  distinguished  from 
Huntington's  chorea  by  the  absence  of  a  hereditary  history. 
The  diagnosis  of  senile  chorea  is  made  from  the  age  of  the  patient 
and  the  usual  presence  of  tremor. 

Cardiac  affections,  when  they  occur,  are  generally  of  a  degen- 
erative nature. 

The  treatment  is  the  same  as  that  prescribed  in  chorea  minor, 
and  includes  rest,  general  building  up  of  the  system,  antirheu- 
matic remedies,  arsenic,  tonics,  and  sedatives,  if  necessary. 


CONGENITAL    CHOREA  547 

CHOREA   ACCOMPANYING    ORGANIC   BRAIN   LESIONS 

Choreiform  movements  may  develop  during  the  course  of  or 
follow  organic  cerebrospinal  disease.  When  they  occur,  these 
abnormal  movements  differ  in  no  way  from  those  seen  in  chorea 
minor.  The  organic  diseases  of  the  nervous  system  that  are 
most  frequently  followed  by  choreiform  movements  are  hemi- 
plegia, meningitis,  idiocy,  etc. 

In  posthemiplegic  chorea  the  movements  are  generally  limited 
to  the  affected  side,  but  they  may  be  bilateral.  It  is,  of  course, 
possible  for  an  acute  chorea  to  develop  in  a  mentally  deficient 
individual,  in  one  who  has  had  meningitis,  or  in  one  who  has 
sustained  a  hemiplegic  attack;  when  it  occurs  under  these  condi- 
tions the  chorea  differs  in  no  way  from  the  ordinary  form  of 
chorea,  except  that  the  outlook  for  recovery  is  not  quite  so  good. 
If,  on  the  other  hand,  the  choreiform  movements  follow  the 
organic  disease  more  or  less  closely,  the  outlook  as  regards  cure 
of  the  choreiform  movements  is  extremely  unfavorable,  the 
condition  generally  becoming  permanent. 

In  these  patients  emotional  disturbances  tend  to  increase  the 
movements,  Avhereas  they  generally  cease  during  sl-eep.  Athetoid 
movements  are  also  frequently  present  in  those  individuals. 

The  treatment  should  be  directed  toward  the  underlying 
organic  disease.  If  the  restlessness  is  marked,  it  may  be  nec- 
essary to  quiet  the  patient  by  the  administration  of  bromids 
and  chloral. 

CONGENITAL   CHOREA 

Choreiform  movements  may  be  present  at  birth  or  appear 
shortly  after.  The  children  in  whom  these  abnormal  move- 
ments occur,  if  they  live,  are  apt  to  be  idiots,  imbeciles,  or  very 
slow  in  their  intellectual  development. 

In  addition  to  the  choreic  movements  and  mental  deficiency 
there  is  generally  present  a  weakness  or  a  paralysis  which  may 
be  of  the  flaccid  or  spastic  t}"pe;  athetoid  movements  are  also 
usually  present. 

As  a  rule,  the  movements  affect  the  face  or  the  upper  extrem- 
ities to  a  greater  extent  than  the  trunk  and  the  lower  extremities. 


548  MANUAL   or   NERVOUS   DISEASES 

They  are  similar  to  the  movements  of  chorea  minor,  except  that 
they  are  apt  to  have  a  greater  range.  They  resemble  the  move- 
ments of  chorea  minor  in  so  far  as  they  are  rendered  worse  by 
emotion  and  are  generally  suspended  during  sleep.  No  rela- 
tionship exists  between  this  form  of  chorea  and  rheumatism — 
cardiac  lesions  are  not  present,  nor  is  there  any  increase  in 
temperature,  joint  involvement,  etc. 

The  course  of  the  disease  is  chronic^  and  treatment  has  no 
effect  upon  the  condition. 


EPIDEMIC   CHOREA 

Epidemic  chorea  was  first  known  to  occur  in  Germany  during 
the  fourteenth  and  fifteenth  century.  It  is  completely  distinct 
from  the  forms  of  chorea  that  have  previously  been  described. 
The  movements  may  have  nothing  in  common  with  true  chore- 
iform movements,  but  as  the  result  of  imitating  others  peculiar 
movements  of  the  extremities  and  body  occur,  and  the  individ- 
ual jumps,  dances,  etc.  Epidemics  of  this-  kind  occurred  as  early 
as  the  thirteenth  century,  and  have  been  described  from  time 
to  time  at  later  periods. 

Etiology. — ^These  epidemics  occur  only  under  unusual  condi- 
tions, as  when  groups  of  persons  are  laboring  under  strong 
emotional  excitement  or  are  subject  to  intense  nervous  strain. 
It  is  under  such  conditions  that  imitation  is  especially  apt  to 
occur,  the  individual  being  generally  in  a  receptive  mood  and 
calm  judgment  being  quite  impossible. 

Symptoms. — ^An  individual  or  a  group  of  persons  imitate 
or  originate  movements  which  are  purposive  in  character  and 
can  be  produced  voluntarily.  In  some  instances  the  move- 
ments become  intense  and  violent,  and  continue  until  the  in- 
dividual falls  from  sheer  exhaustion. 

Course. — ^The  onset  is  usually  more  or  less  sudden,  and  the 
condition  may  last  a  longer  or  a  shorter  period.  Exacerbations 
or  remissions  occur,  and  there  is  either  a  sudden  or  a  gradual 
termination,  the  former  being  most  frequent.  The  epidemics 
are  usually  of  gradual  growth  and  recede  slowly. 


ELECTRIC    CHOREA  549 

The  prognosis  is  good,  and  the  treatment  is  the  same  as  that 
applied  in  hysteria. 

ELECTRIC   CHOREA 

Various  conditions  have  been  described  under  this  term. 

Dubini's  disease  is  a  form  of  electric  chorea  seen  most  com- 
monly in  the  northern  part  of  Italy,  but  even  there  it  is  of  very 
rare  occurrence.  It  is  believed  to  be  an  acute  infection,  in 
which  toxic  substances  first  attack  the  neurons  of  the  cerebral 
cortex.  This  is  manifested  by  the  frequent  onset  of  the  disease 
with  convulsions,  and  by  the  occurrence  of  unilateral  symptoms, 
w^hich  later  become  generalized.  As  the  disease  progresses  the 
anterior  horn  cells  become  affected,  and  muscular  atrophy 
occurs. 

Symptoms. — The  disease  usually  begins  with  pain  in  the  neck 
and  back  and  fever,  which  varies  in  degree  according  to  the 
severity  of  the  affection.  Generalized  or  convulsions  limited  to 
one  side  may  occur.  In  conjunction  w4th  the  convulsions,  or 
even  in  their  absence,  the  characteristic  features  of  the  disease 
appear — rigid  muscular  contractions,  similar  to  those  elicited 
by  electric  stimulation.  First  one  arm  and  one  side  of  the  face 
is  involved,  and  later  the  leg  upon  the  same  side;  finally  the 
opposite  side  of  the  trunk  becomes  affected.  If  the  condition 
progresses,  paralysis  of  an  atrophic  type  occurs,  the  portions  of 
the  body  becoming  affected  in  the  same  order  in  which  the  mus- 
cular contractions  occur.  The  weakness  is  gradually  progressive 
until,  in  the  end,  it  becomes  general.  Atrophy  with  reaction 
of  degeneration  takes  place.  The  disease  runs  a  progressive 
course,  death  occurring  in  from  a  few  days  to  several  months. 

Under  the  term  electric  chorea  Bergeron  has  described  an 
affection  which  occurs  in  anemic  children,  and  is  usually  observed 
between  the  ages  of  seven  and  fourteen. 

Etiology. — ^This  form  of  electric  chorea  is  believed  to  be  caused 
by  some  form  of  gastric  irritation. 

Symptoms. — In  this  condition  violent  twitchings  occur  which 
come  on  in  spasmodic  attacks.  The  movements  are  rhythmic 
and  are  similar  to  those  which  can  be  produced  by  regularly 
interrupted  electric  stimulation.    These  movements  are  usually 


550  MANUAL   OF   NERVOUS   DISEASES 

limited  to  certain  groups  of  muscles,  and  are  purposive  in  char- 
acter; they  also  resemble  movements  which  could  be  produced 
voluntarily:  the  head  may  be  tossed  from  side  to  side  or  back- 
ward and  forward;  the  shoulders  may  be  elevated,  the  forearms 
flexed  and  extended,  etc.  These  movements  may  be  confined 
to  one  extremity,  to  single  muscles,  or  may  involve  the  entire 
musculature  of  the  body.  They  are  rendered  worse  by  emo- 
tional excitement  and  by  attempts  to  repress  them,  and  dis- 
appear during  sleep.  Examination  of  the  patient  for  pathologic 
conditions  is  negative. 

The  prognosis  in  these  cases  is  very  good.  Usually  after 
running  a  very  brief  course  the  disease  ends  in  complete  recovery. 

Diagnosis. — This  condition  is  to  be  differentiated  from  hys- 
teria, such  differentiation  being  difficult  and  often  impossible. 
The  limitation  of  the  movements  to  certain  parts  of  the  body 
and  the  constancy  of  involvement  of  that  particular  part  of  the 
body  should  assist  one  in  making  the  differentiation. 

Treatment. — ^The  affected  child  should  be  isolated,  and  placed 
amid  pleasant  hygienic  surroundings.  It  is  most  important 
that  the  gastro-intestinal  tract  be  properly  cleansed  by  the 
administration'  of  calomel,  castor  oil,  or  other  purgatives.  The 
diet  should  be  regulated,  and  should  be  of  a  light,  nutritious 
nature.  As  these  children  are  usually  anemic  and  under- 
nourished, tonics,  and  especially  arsenic,  are  indicated.  Cold 
douches,  Scotch  douches,  and,  as  soon  as  possible,  proper 
gymnastic  exercises  are  all  to  be  recommended. 

Henoch  has  also  described  a  form  of  efectric  chorea  which 
occurs  in  childhood.  This  condition  is  also  characterized  by 
lightning-like  muscular  contractions  which  affect  especially  the 
muscles  of  the  neck  and  shoulders.  The  affection  described  by 
Henoch  closely  resembles  the  type  of  chorea  described  by 
Bergeron. 

PARALYSIS   AGITANS    (SHAKING    PALSY;    PARKIN- 
SON'S DISEASE) 

Paralysis  agitans  is  a  disease  of  the  nervous  and  muscular 
system,  which  manifests  itself  usually  between  the  fortieth  and 


PARALYSIS    AGITANS  55 1 

the  sixtieth  year.  It  is  characterized  by  the  occurrence  of 
tremor,  muscle  rigidity,  and  abnormal  sensations. 

Etiology. — This  disease,  as  stated,  manifests  itself  generally 
between  the  fortieth  and  the  sixtieth  year,  although  it  occurs  in 
rare  cases  before  the  thirtieth  year  and  in  a  considerable  number 
of  cases  after  the  sixtieth  year.  It  is  more  common  in  men  than 
in  women.  Heredity  may  play  a  small  part  in  acting  as  a 
predisposing  cause,  but  it  is  certainly  not  of  much  importance. 
In  many  cases  no  ascertainable  cause  can  be  discovered.  The 
most  common  and  most  important  exciting  causes  of  this  con- 
dition seem  to  be  prolonged  anxiety,  worry,  emotional  shock, 
fright,  overw^ork,  and  exposure.  In  some  cases  the  disease 
sets  in  within  a  short  period  after  exposure  or  injury,  or  after 
prolonged  worr\^  and  anxiety. 

Pathology. — The  lesions  which  are  most  commonly  found  in 
paralysis  agitans  are  degenerative  changes  in  the  vessels  and  a 
proliferation  of  the  glial  tissue;  the  muscle-fibers  also  show 
slight  atrophic  changes;  some  of  these  changes  are  certainly 
of  a  senile  nature;  they  are  not  found  constantly  in  all  cases. 
At  the  present  time  there  is  no  consensus  of  opinion  as  regards 
the  cause  or  pathology  of  the  disease,  and  it  is  considered  to  be 
a  functional  condition. 

It  is  probable  that  with  other  methods  of  investigation  a 
true  causative  factor  and  most  likely  pathologic  changes  will  be 
found. 

Symptoms. — The  disease  is  generally  of  slow  onset,  although 
in  a  few  cases  the  symptoms  rapidly  foUow  fright,  exposure,  or 
marked  emotional  disturbances.  In  cases  of  gradual  onset, 
usually  for  some  considerable  time,  the  patient  complains  of 
an  aching,  stiff  feeling  in  the  back  and  extremities,  and  later 
the  characteristic  symptoms  of  the  disease  gradually  develop. 
The  most  common  symptom  is  tremor,  which  affects  chiefly 
the  extremities,  especially  the  upper,  and  particularly  the  hands 
and  fingers.  The  tremor  usually  aff'ects  one  extremity  first, 
and  early  in  the  disease  one  limb  is  involved  to  a  greater  extent 
than  the  other.  As  the  disease  advances  the  limbs  become 
equally  affected. 

The  tremor  is  characterized  by  the  fact  that  it  occurs  while 


552  MANUAL   OF   NERVOUS   DISEASES 

the  patient  is  at  rest,  and  that,  early  in  the  disease,  it  can  be 
inhibited  by  an  effort  of  the  will.  It  is  of  a  slow  type,  four  or 
five  oscillations  occurring  to  the  second. 

The  range  of  the  movements  is  usually  within  narrow  limits. 
In  the  upper  extremities  the  tremor  takes  the  form  of  flexion 
and  extension  and  abduction  and  adduction  of  the  fingers  and 
flexion  and  extension  and  pronation  and  supination  of  the  hands. 
The  tremor  of  the  thumb  and  index-finger  is  of  such  a  character 
as  to  give  rise  to  a  movement  as  if  one  were  rolling  a  pill.  After 
the  disease  is  once  well  extablished,  the  tremor  is  more  or  less 
constant  in  amplitude  and  in  rate,  although  it  may  be  inhibited 
temporarily  by  volition  or  during  the  performance  of  some 
purposive  act.  It  persists,  nevertheless,  or  is  sometimes  in- 
creased while  making  continuous  movements,  such  as  in  writing, 
etc.  The  tremor  is  practically  always  aggravated  by  excite- 
ment and  by  emotional  disturbances.  The  hand-writing  of  the 
patient  is  characterized  by  the  smallness  of  the  letters  and  by 
the  symmetrically  wavy  outlines  and  strokes. 

When  the  tremor  affects  the  lower  extremities,  extension, 
flexion,  adduction,  and  abduction  of  the  foot  usually  occur. 
The  muscles  of  the  thigh  are  also  often  involved.  The  tremor 
does  not,  as  a  rule,  involve  the  muscles  of  the  neck,  but  not 
uncommonly  it  affects  the  muscles  of  the  lower  jaw,  chin,  lips, 
and  tongue.     The  tremor  generally  ceases  during  sleep. 

The  second  of  the  cardinal  symptoms  is  chronic  muscular 
rigidity,  which  affects  practically  the  entire  musculature  of  the 
body.  The  muscles  of  the  back,  neck,  and  throat  are  usually 
affected  to  a  more  marked  extent,  and  in  the  great  majority  of 
cases  the  muscles  of  the  face  are  involved.  This  muscular 
rigidity  causes  certain  changes  of  posture.  The  muscular 
rigidity  and  its  subsequent  alterations  of  posture  may  constitute 
the  first  sign  of  the  disease.  The  attitude  of  a  patient  in  whom 
the  muscular  rigidity  is  at  all  marked  is  one  in  which  the  head 
and  trunk  are  bent  forward,  the  arms  held  close  to  the  side,  the 
elbows  slightly  flexed,  the  wrists  slightly  extended,  and  the  fingers 
partially  flexed  at  the  metacarpophalangeal  joints,  whereas  the 
middle  and  terminal  phalanges  are  extended,  with  the  thumb  ad- 
ducted  (Fig.  156).   The  legs  are  moderately  flexed  at  the  hip-  and 


PARALYSIS    AGITANS 


553 


knee-joints,  with  often  an  adduction  of  the  thighs.  As  the  result 
of  rigidity  of  the  facial  muscles  the  face  presents  a  peculiar, 
expressionless,  mask-like  appearance.  Even  early  in  the  disease 
a  slowness  or  clumsiness  of  complex  voluntary  movements  are 
noticed;  it  appears  as  if  there  were  a  delay  in  the  conversion  of 
a  volitional  impulse  into  a  muscle  response,  and  as  if  the  muscles 
responded  more  slowly  than  normally.  This  is  well  seen  in  the 
difficulty  the  patient  experiences  in  dressing  and  in  undressing 


Fig.  156.— Position  of  hands  in  Parkinson's  disease. 


and  in  changing  his  position.  Many  of  these  patients  must  be 
assisted  in  dressing  and  in  undressing,  and  later  in  the  disease 
in  changing  their  position.  The  gait  also  undergoes  a  deviation 
from  the  normal.  The  patient  stoops  forward,  walking  slowly 
at  first,  and  then  gradually  more  and  more  rapidly.  He  appears 
as  if  about  to  fall  for\A'ard — a  condition  that  is  called  propul- 
sion (Fig.  157).  If  these  patients  are  told  to  walk  backward, 
sometimes  the  same  condition  occurs,  and  they  either  fall  or 


554 


MANUAL   OF   NERVOUS   DISEASES 


their  progress   is   stopped  by   some   immovable   object;    this 
condition  is  termed  "retropulsion." 

The  tendon  reflexes  are  usually  increased,  but  may  be  normal. 
True  clonus  and  the  Babinski  sign  are  never  present.  Paralysis 
does  not  occur,  and  even  in  the  most  advanced  cases  some 
degree  of  motility  is  retained;  this  may,  however,  as  the  result 


Fig.  157. — Posture  in  Parkinson's  disease. 


of  the  muscle  rigidity  and  of  retardation  of  muscle  response  be 
very  limited. 

Speech  is  usually  very  monotonous.  The  voice  is  generally 
low,  and  at  times  the  individual  has  difficulty  in  producing  the 
first  sound,  but  as  soon  as  this  is  done  the  words  flow  rapidly, 
and  in  some  cases  more  rapidly  than  normal.  Hyperidrosis 
and  an  increased  flow  of  saliva  occur  very  commonly,  and  in 


PARALYSIS    AGITANS  555 

some  cases  salivation  appears,  giving  rise  to  considerable 
discomfort. 

Sensalion. — Tactile,  pain,  temperature,  and  muscle  sensations 
are  not  disturbed.  Pain,  which  is  subacute  in  character  and 
described  as  an  aching  and  stiffness,  is  generally  complained  of 
from  the  lirst;  in  fact,  many  of  these  patients  are  treated  for 
rheumatism  long  before  the  true  condition  is  discovered.  In 
many  cases  the  sense  of  stiffness  and  aching  is  complained  of 
throughout  the  entire  course  of  the  disease. 

Paresthesias,  such  as  a  sensation  as  of  heat — a  feeling  as  if  hot 
water  were  being  poured  over  the  body;  or  a  sensation  of  cold — 
a  feeling  as  if  cold  air  were  being  blown  upon  the  body,  numbness, 
tingling,  etc.,  are  very  frequently  complained  of.  These  pares- 
thesias are  among  the  most  constant  symptoms  of  the  disease. 

The  mental  state  of  the  patient  is-nsually  unimpaired,  but  as 
the  disease  progresses  these  patients  become  anxious,  restless, 
irritable,  depressed,  and  emotional ;  in  some  few  cases  the  opposite 
condition  develops,  and  in  spite  of  the  physical  handicap  the 
patient  develops  a  certain  geniality  of  disposition. 

Course. — ^The  development  and  progress  of  the  disease  are 
usually  slow.  It  may  begin  with  tremor  or  with  a  sensation 
of  aching  and  stiffness — ^first  in  one  extremity,  and  then  grad- 
ually spreading.  In  some  cases  it  appears  suddenly  after  fright 
or  emotional  disturbance.  The  posture,  gait,  mask-like  ex- 
pression of  the  face,  etc.,  gradually  become  manifest  as  the  dis- 
ease advances.  At  any  time  during  the  course  of  the  disease 
remissions  may  occur.  It  usually  runs  a  gradually  progressive 
course,  lasting  many  years. 

Prognosis. — ^The  prognosis  as  to  recovery  is  very  unf avoralile ; 
as  to  life  it  is  good,  for  the  affected  individuals  do  not  die  of  this 
disease.  Hemiplegic  and  apoplectic  attacks  may  occur  during 
the  course  of  the  disease,  but  are  no  more  prone  to  occur  in 
these  patients  than  they  are  in  unaffected  individuals  of  the 
same  age. 

Diagnosis. — WTien  the  disease  is  once  well  developed,  little 
or  no  difi&culty  will  be  experienced  in  making  the  diagnosis. 
The  appearance  of  the  characteristic  tremor,  the  aching,  and  the 
muscular  rigiditv  easilv  lead  one  to  a  correct  conclusion.     The 


556  MANUAL   OF  NERVOUS   DISEASES 

disease  is  differentiated  from  multiple  sclerosis  by  the  fact  that 
in  paralysis  agitans  the  tremor  is  decreased  upon  voluntary 
effort  and  increased  in  multiple  sclerosis.  In  the  former  disease 
the  tremor  is  of  limited  amplitude,  and  in  the  latter  disease  the 
amplitude  increases  upon  voluntary  effort;  in  the  former  disease 
nystagmus  does  not  occur,  whereas  in  the  latter  it  is  frequently 
present.  The  speech  in  the  former  disease  is  weak,  whereas  in 
the  latter  it  is  slow  and  scanning.  Paralysis  agitans  is  a  disease 
of  advanced  life,  whereas  multiple  sclerosis  occurs  in  young 
adults. 

Paralysis  agitans  must  sometimes  be  differentiated  from 
paresis:  in  the  latter  disease  the  tremor  is  finer,  is  increased  upon 
voluntary  motion,  and  pupillary  disturbances  are  present,  as 
well  as  disturbances  of  speech,  mental  manifestations,  etc.,  all 
these  symptoms  being  absent  or  quite  different  in  paralysis 
agitans.  From  senile  tremors  paralysis  agitans  is  differentiated 
by  the  fact  that  in  senility  the  tremor  generally  involves  the 
head,  the  legs  being  rarely  involved;  there  is  an  absence  of  the 
mask-like  expression  of  the  face,  the  posture  of  the  hands  and 
body  is  quite  different  from  that  of  paralysis  agitans,  and  in 
advanced  cases  paralysis,  sensory  disturbances,  etc.,  are  fre- 
quently present. 

Treatment. — ^A  person  afflicted  with  paralysis  agitans  should 
lead  a  life  free  from  excitement  and  worry;  he  should  live  amid 
pleasant  surroundings,  and  if  his  condition  permits,  he  should 
follow  a  congenial  occupation.  Change  of  scene  is  also  advis- 
able. 

Overexertion,  both  physical  and  mental,  should  be  absolutely 
avoided,  since  it  hastens  the  progress  and  intensifies  the  symp- 
toms of  the  disease.  All  strenuous  treatment,  such  as  violent 
exercise,  very  hot  or  very  cold  baths,  deep-seated  massage,  and 
the  like,  is  contraindicated.  Warm  salt  rubs,  sponging  with 
warm  water,  and  gentle  massage  are  of  benefit,  and  one  of  these 
measures  should  be  carried  out  at  least  three  times  a  week. 
The  diet  should  be  light  and  nutritious,  and  the  bowels  be  kept 
freely  open.  Exposure  in  too  cold  or  too  hot  weather  is  to  be 
avoided. 

At  the  present  time  no  drug  is  known  that  has  a  curative  effect 


EPILEPSY  (falling  sickness)  557 

upon  this  disease.  There  are  several  remedies,  however,  which 
tend  to  render  the  patient  much  more  comfortable  and  to  a 
certain  extent  to  decrease  the  tremor;  such  remedies,  even  when 
administered  over  a  period  of  several  years ,  do  not  seem  to 
produce  harmful  effects.  Tincture  of  veratrum  viride,  given  in 
doses  of  from  3  to  5  drops  three  times  a  day,  will  sometimes 
lessen  the  intensity  of  the  tremor;  tincture  of  gelsemium  also 
at  times  exerts  a  beneficial  effect.  Sulphate  of  duboisin  is  also 
highly  recommended;  hyoscyamin  hydrobromid,  tto  grain  three 
times  a  day,  has  given  very  good  results,  especially  in  those  cases 
in  which  there  is  an  increase  in  the  salivary  secretions. 

I  have  found  that  the  combination  of  codein  with  these  drugs 
usually  tends  to  increase  the  comfort  of  the  patient,  particularly 
when  there  is  much  complaint  of  muscle  stiffness. 

EPILEPSY   (FALLING   SICKNESS) 

Epilepsy  is  a  disease  characterized  by  a  sudden  disturbance  of 
consciousness,  which  may  occur  with  or  without  warning,  and 
which  may  be  attended  by  more  or  less  marked  disturbance  of 
motility.  Three  forms  of  epilepsy  are  known — major  epilepsy, 
minor  epilepsy,  and  psychic  epilepsy.  Major  epilepsy,  or 
grand  mal,  is  a  condition  in  which  a  sudden  loss  of  consciousness 
occurs  with  or  without  warning,  which  is  immediately  followed 
by  a  generalized  convulsive  seizure  which  is  at  first  tonic  and 
then  clonic. 

Minor  epilepsy,  or  petit  mal,  is  a  condition  characterized  by 
sudden  loss  of  consciousness,  which  is  usually  of  very  short 
duration,  and  which  may  or  may  not  be  attended  by  abnor- 
malities of  movement,  which,  if  present,  are  generally  of  very 
moderate  degree. 

Psychic  epilepsy  is  a  condition  in  which,  either  with  or  without 
warning,  there  is  a  sudden  perversion  of  consciousness,  which 
may  endure  for  a  long  or  a  short  period,  during  which  the  in- 
dividual is  capable  of  carrying  on  complex  activities  of  which 
he  has  absolutely  no  recollection  after  the  attack  disappears. 

Epileptiform  seizures  may  be  either  idiopathic, — i.  e.,  occur 
without  ascertainable  cause, — or  they  may  be  symptomatic, — 


558  MANUAL   or   NERVOUS   DISEASES 

that  is,  they  may  be  the  evidence  of  a  disturbance  or  a  perversion 
of  the  functions  of  the  brain  due  to  some  underlying  disease. 

Jacksonian  epilepsy  is  a  type  of  symptomatic  epilepsy  in 
which  there  is  no  disturbance  of  consciousness.  It  is  caused  by 
irritation  of  a  localized  area  of  the  brain. 

Nocturnal  epilepsy  is  a  term  applied  to  epileptic  seizures  that 
occur  only  during  the  night,  and  may  remain  undetected  for  a 
long  time. 

Etiology. —  Heredity. — In  a  large  number  of  cases  of  idiopathic 
epilepsy  there  is  a  distinct  hereditary  history  of  the  existence  of 
a  neuropathic  taint,  debilitating  disease,  mental  disorders, 
s>^hilis,  chronic  intoxication,  especially  alcohol,  etc.  In  a 
small  proportion  of  cases  there  is  a  history  of  epilepsy  having 
existed  in  previous  generations. 

Age. — In  a  great  many  cases  epileptic  attacks  appear  for  the 
first  time  before  the  age  of  twenty.  In  about  one-third  of  the 
cases  they  appear  before  the  tenth  year,  and  in  another  third 
before  the  twentieth  year.  Epileptiform  seizures  which  occur 
for  the  first  time  after  the  twentieth  year  should  always  arouse 
grave  suspicion  of  the  presence  of  an  organic  disease,  or  of  a 
toxic  condition  of  exogenous  or  endogenous  origin.  The  disease 
occurs  somewhat  more  frequently  in  males  than  in  females. 

Chronic  poisoning  from  alcohol  or  lead,  or  toxic  conditions  of 
the  gastro-intestinal  tract  may  either  bring  about  changes  in  the 
cerebral  substance  and  predispose  to  the  occurrence  of  epileptic 
seizures,  or,  as  the  result  of  an  acute  poisoning,  may  be  the  direct 
exciting  cause  of  an  epileptiform  seizure.  Acute  infectious 
diseases,  such  as  scarlet  fever,  measles,  typhoid,  influenza,  etc., 
may  be  followed  by  epilepsy;  it  is  probably  under  these  conditions 
that  organic  changes  have  taken  place  in  the  cerebral  cortex, 
as  the  result  either  of  a  toxemia  or  of  an  infection. 

Trauma. — Injury  to  the  head  may  cause  localized  cortical 
lesions  that  are  followed  by  Jacksonian  or  general  epileptiform 
seizures.  Blows  or  falls,  without  apparent  localized  cerebral  le- 
sions, may  be  the  exciting  cause  of  generalized  epileptiform 
seizures.  Syphilis  may  be  the  etiologic  factor  in  generalized 
epileptiform  seizures,  but  in  most  cases  the  epileptiform  seizures 
that  occur  in  cerebral  syphilis  are  merely  symptomatic  of  the 


EPILEPSY    (falling    SICKNESS)  559 

underlying  disease.  Prolonged  exposure  to  very  hot  or  very  cold 
weather,  overexertion,  fright,  anxiety,  long-continued  worry, 
etc.,  are  also  among  the  probable  exciting  causes  of  the  disease. 

Reflex  Causes. — In  predisposed  individuals  a  prolonged  nerv^e 
irritant  is  capable  of  precipitating  an  epileptic  condition. 
Among  the  common  reflex  causes  are  errors  of  refraction,  in- 
intestinal  worms,  diseases  of  the  throat  and  nose,  caries  or 
unerupted  teeth,  phimosis,  diseases  of  the  heart,  abdominal 
organs,  or  pelvic  viscera,  and  scars  pressing  upon  or  including 
nerves,  etc. 

Chronic  Cerebral  Disease. — Meningitis,  hydrocephalus,vascular 
disturbances,  anomalies  of  development,  etc.,  may  also  be  the 
underlying  causes  of  epilepsy. 

Chronic  nutritional  disorders,  such  as  rickets,  scurvy,  disturb- 
ance of  the  secretions  of  the  ductless  glands,  nephritis,  diabetes, 
tuberculosis,  etc.,  may  be  predisposing  or  exciting  causes  of 
epilepsy. 

Pathology. — ^As  a  rule,  a  careful  examination  of  the  nervous 
system  and  of  the  organs  of  the  body  after  death  yields  negative 
results.  The  findings  which  are  discovered  are  certainly  not 
constant.  In  many  cases  a  careful  histologic  investigation  has 
revealed  the  presence  of  atroph}'  of  the  nerve-cells,  wdth  prolifera- 
tion of  the  glial  fibers  in  the  cortex. 

The  consensus  of  opinion  at  the  present  time  is  that  in  epilepsy 
the  pathologic  lesion  is  situated  in  the  cortex  of  the  brain. 
Several  theories  as  to  the  causation  of  the  attacks  exist.  Under- 
lying all  these  theories  is  the  assumption  that  a  neural  tissue  in  a 
state  of  easily  disturbed  equilibrium  exists.  When  one  takes 
into  consideration  the  facts  that  epileptiform  seizures  can  be 
produced  by  intentional  irritation  of  the  cerebral  cortex;  that 
they  occur  wdth  such  frequency  in  organic  diseases  of  the  brain, 
and  that  they  occur  so  often  in  individuals  who  show  evidence 
of  maldevelopment  of  the  brain;  that  when  an  aura  exists,  it  is 
alw'ays  constant  and  points  to  some  local  cerebral  area;  that 
individuals  may  show  definite  mental  deficiencies  without 
apparent  histologic  changes  in  the  brain — when  one  considers 
all  these  facts  one  is  led,  more  or  less  definitely,  to  the  conclusion 
that  the  underlying  cause  of  epilepsy  is  some  deficiency  in  the 


560  MANUAL  OF  NERVOUS  DISEASES 

inhibitive  power  of  the  cortical  cells;  that  this  inhibitive  power 
may  be  decreased  either  as  the  result  of  defective  heredity  or  in 
consequence  of  organic  destructive  disease  of  the  cortex ;  such 
destructive  condition  may  be  of  such  character  as  to  be  easily 
discernible,  or,  with  the  present  methods  of  investigations, 
may  elude  discovery.  Furthermore,  that  the  inhibitory  power 
of  the  cortical  cells  may  be  decreased,  either  slowly,  by  the 
prolonged  action  of  the  toxic  substances,  or  more  or  less  acutely, 
by  being  suddenly  overwhelmed  by  large  doses  of  poisonous 
substances;  as  the  result  of  disturbances  of  nutrition  of  the 
cerebral  cells,  or  because  of  the  vascular  disturbance  where  there 
is  defective  nourishment  of  these  cells.  The  epileptic  attacks 
are  the  result  of  some  added  irritant  acting  upon  cells  whose 
inhibitory  power  is  below  normal.  These  added  irritants  may 
be  reflex  excitations,  emotional  disturbances,  toxemias,  etc. 

Symptoms. — In  some  cases  the  epileptic  attack  is  the  only 
symptom  of  the  disease,  the  individual  being  apparently  normal 
in  the  interval  between  the  attacks.  In  about  50  or  60  per  cent. 
of  cases  the  epileptic  attack  is  preceded  by  a  warning,  termed  an 
aura,  which  occurs  from  a  few  seconds  to  some  considerable 
time  before  the  attack,  and  is  alwa3^s  constant  in  character.  In 
some  cases,  especially  after  the  disease  has  persisted  for  a  con- 
siderable length  of  time,  symptoms  of  disturbance  of  the  general 
health  or  changes  in  character,  emotional  tone,  or  mental 
condition  appear  in  the  intervals  between  the  attacks. 

The  aura,  or  warning,  which  maybe  motor,  sensory,  vasomotor, 
or  psychic,  may  not  give  the  patient  sufficient  time,  before  the 
onset  of  the  attack,  to  summon  assistance  or  to  take  measures 
to  protect  himself  from  the  consequences  of  the  attack.  In 
many  cases  there  is  an  appreciable  interval  between  the  aura 
and  the  attack,  and  occasionally  the  aura  may  occur  several 
hours  or  more  before  the  onset  of  the  seizure.  The  aura  mani- 
fests itself  in  many  ways,  but  is  always  constant  in  the  same 
individual.  The  commoner  types  of  aura  are:  Peculiarities  of 
sensation,  many  patients  complaining  of  a  peculiar  sinking, 
disturbed,  empty  feeling  in  the  epigastric  region;  some  ex- 
perience a  feeling  of  vertigo,  numbness  in  the  upper  and  lower 
extremities,  peculiar  mental  states,  such  as  a  sense  of  fear,  of 


EPILEPSY    (falling    SICKNESS)  56 1 

elation,  of  uncertainty,  of  restlessness,  of  depression,  etc.;  others 
have  a  peculiar  sensation  about  the  heart  or  in  the  abdominal 
cavity,  nausea,  a  feeling  of  fulness  in  the  head,  sensations  of 
heat  or  cold,  or  flushing,  drowsiness,  or  excitement,  hallucina- 
tions of  sight,  hearing,  smell,  and  taste,  sudden  flashes  of  light  or 
blindness,  general  trembling,  increased  secretion  of  saliva,  attacks 
of  diarrhea  without  cause,  etc.  Occasionally  the  aura  may  occur 
and  no  seizure  follow. 

The  attack,  which  is  the  chief  manifestation  of  the  disease, 
occurs  more  or  less  suddenly,  either  with  or  without  the 
aura.  In  the  grand  mal  type  of  epilepsy  there  is  loss  of 
consciousness,  in  some  cases  accompanied  by  a  sudden  cry 
or  groan;  in  other  cases  the  cry  may  be  absent  and  the  head 
be  drawn  to  one  side  or  drawTi  backward,  the  eyes  rotat- 
ing either  upward  or  downward;  the  pupils  are  dilated,  the 
patient  falls,  and  the  face  is  pale;  nearly  all  the  muscles 
become  tonically  contracted,  and  the  face  gradually  becomes 
cyanotic;  it  is  during  this  state,  which  may  last  from  a  few 
seconds  to  from  forty  to  fifty  seconds,  that  the  patient  bites 
the  tongue,  owing  to  the  fact  that,  in  the  tonic  spasm,  the 
tongue  is  protruded  between  the  teeth,  which  close  on  account 
of  the  tonic  contraction  of  the  jaw  muscles.  The  cyanosis  is 
due  to  the  tonic  contraction  of  the  thorax  and  abdominal  muscles, 
which  prevents  respiration  from  taking  place.  It  is  also  during 
this  stage  that  the  thumb  is  strongly  flexed  against  the  palm  and 
the  fingers  flexed  over  the  thumb;  the  arms  are  usually  flexed, 
and  the  legs  and  feet  are  extended.  The  contents  of  the  bladder 
and  rectum  are  sometimes  expelled  as  the  result  of  the  tonic 
spasms  of  the  muscles  that  govern  these  organs. 

Following  this  stage  clonic  spasms,  at  first  limited  in  extent, 
but  gradually  becoming  more  violent  in  character,  occur.  These 
clonic  spasms  may  affect  all  the  muscles  of  the  face,  trunk,  and 
extremities.  During  this  stage  the  breathing  becomes  loud  and 
stertorous,  and  saliva,  sometimes  blood-stained  if  the  patient 
has  bitten  himself,  flows  from  the  mouth.  At  this  time  the 
patient  may  also  bite  his  tongue  or  otherwise  severely  injure 
himself.  The  extent  of  the  muscular  movements  varies  in 
different  patients,  and  depends  upon  the  severity  of  the  seizure: 
36 


562  MANUAL   or   NERVOUS   DISEASES 

in  some  individuals  the  convulsive  movements  are  limited  to  a 
few  muscles,  and  are  only  moderately  severe,  whereas  in  others 
the  convulsive  movements  involve  all  the  muscles  and  are 
extremely  severe,  and  consist  of  violent  thrashing  movements  of 
the  extremities  and  trunk.  Dislocations  and  fractures  may 
occur  during  this  stage  as  the  result  of  the  violent  muscular 
movements. 

The  clonic  stage  lasts  for  from  one  to  five  or  ten  minutes,  and 
sometimes  longer.  The  muscular  movements  gradually  become 
less  severe,  and  the  patient  slowly  regains  consciousness.  After 
the  seizure  the  patient  is  dazed,  does  not  realize  what  has  hap- 
pened, but  gradually,  within  half  an  hour,  he  comes  to  himself. 
In  many  cases  the  patient  passes  from  the  convulsive  state  into 
one  of  deep  sleep,  which  lasts  for  several  hours,  and  from  which 
it  is  difficult  or  almost  impossible  to  arouse  him.  Other  patients, 
after  a  brief  period  of  dulness  or  confusion,  become  perfectly 
normal  and  are  able  to  continue  the  occupation  in  which  they 
were  engaged  when  the  seizure  occurred. 

Following  an  attack  the  patient  is  usually  much  fatigued, 
complains  of  weakness  and  headache,  or  of  pain  the  result  of 
an  injury  sustained  during  the  attack.  Generally,  the  last 
thing  the  patient  remembers  is  the  aura,  or  any  duty  with  which 
he  was  occupied  immediately  preceding  the  attack.  Patients 
can  usually  tell  that  they  have  had  an  attack  from  the  feeling 
of  exhaustion,  weakness,  and  fatigue,  or  from  the  presence  of 
an  injury  which  was  inflicted  during  the  attack. 

As  a  rule,  within  twenty-four  hours  after  the  attack  the  patient 
has  entirely  recovered,  unless  he  has  sustained  an  injury. 
Cases  occur,  however,  in  which,  sometimes  for  several  days  after 
the  attack,  sensory  disturbances,  paralysis  or  weakness,  mental 
confusion,  disturbances  of  speech,  etc.,  are  present. 

In  some  cases  the  convulsive  seizure  may  be  very  mild,  and  be 
followed  by  drowsiness  for  a  short  time,  or  immediately  after 
the  attack  the  patient  may  continue  his  occupation  as  if  nothing 
had  occurred.  In  some  few  cases  the  patient  may  be  able  to 
prevent  an  attack  by  taking  certain  precautions  as  soon  as  the 
aura  occurs. 

In  petit  mat,  or  minor  epilepsy,  the  attacks  are  characterized 


EPILEPSY    (falling    SICKNESS)  563 

principally  by  a  loss  of  consciousness.  The  seizures  come  on 
suddenly,  are  rarely  preceded  by  an  aura,  and  usually  last  only 
a  very  short  time — from  a  few  seconds  to  half  a  minute.  The 
disturbance  of  consciousness  passes  off  rapidly,  and  in  many 
cases  the  patient  is  unaware  that  an  attack  has  occurred.  The 
face  is  usually  pale,  the  body  rigid,  and  the  eyes  are  staring. 
The  patient  rarely  falls.  There  are  often  slight  clonic  twitch- 
ings,  especially  of  the  muscles  of  the  face  or  of  the  upper  extrem- 
ities. If  the  patient  is  engaged  in  conversation,  he  suddenly  stops 
talking,  and  those  observing  him  notice  that  something  peculiar 
has  happened;  in  a  few^  seconds  the  patient  may  continue  the 
conversation,  not  realizing  that  it  has  been  interrupted. 

If  the  patient  should  be  engaged  in  some  occupation  or  be 
eating  at  the  time  the  seizure  occurs,  he  may  drop  his  tools, 
upset  objects  in  his  immediate  neighborhood,  drop  the  food  he  is 
conveying  to  his  mouth,  and  a  few  seconds  later,  when  the  attack 
has  passed  off,  he  observes  with  astonishment  what  has  occurred. 
During  the  attack  the  patient  may  make  peculiar  noises,  blink 
his  eyelids,  make  peculiar  movements  with  his  lips  and  tongue, 
etc. 

Psychic  Epilepsy. — In  some  cases,  instead  of  a  loss  of  con- 
sciousness, a  peculiar  mental  state  occurs  in  which  the  patient 
moves  about,  becomes  fretful,  is  restless,  carries  on  complicated 
activities,  may  suddenly  run  aimlessly  about,  exposing  himself, 
etc.  He  has  absolutely  no  recollection  of  the  condition  after  the 
attack  has  passed. 

Attacks  of  minor  epilepsy  are  apt  to  occur  more  frequently 
than  major  attacks,  and  in  some  cases  both  major  and  minor 
attacks  occur.  Seizures  characterized  by  states  of  mental 
confusion,  during  which  complicated  activities  are  carried  on, 
are  of  infrequent  occurrence,  and  can  usually  be  definitely 
diagnosed  only  when  they  occur  in  conjunction  with  either 
major  or  minor  attacks. 

In  an  individual  afflicted  with  epilepsy  there  may  occur  at 
any  time  a  state  in  which  con\Tilsive  seizures  may  follow^  one 
another  in  rapid  succession  over  a  period  lasting  from  several 
hours  to  one,  two,  or  three  days.  This  condition  is  known  as 
status  epilepticus.    This  is  a  very  grave  condition,  and  if  the 


564  MANUAL   OF   NERVOUS   DISEASES 

patient  survives,  it  is  frequently  followed  by  a  period  of  mental 
confusion,  delirium,  weakness  or  paralysis  of  a  transient  nature, 
or  at  times,  if  serious  vascular  disturbances  have  occurred 
during  the  seizure,  the  weakness  or  paralysis  may  become  per- 
manent. In  other  cases  after  such  attacks  sensory  disturbances, 
such  as  paresthesias,  blindness,  deafness,  etc.,  occur,  which  are 
usually  of  a  transient  nature,  but  may  become  permanent. 

At  times,  instead  of  a  convulsive  seizure,  there  occurs  a  dis- 
turbed mental  state  during  which  the  patient  may  carry  on 
complicated  activities,  or  during  which  he  may  become  excited, 
depressed,  or  delirious;  this  condition  is  known  as  epileptic 
equivalent. 

Postepileptic  Mental  States. — Following  a  severe  attack,  or 
a  series  of  attacks,  there  may  occur  any  one  of  the  various  forms 
of  mental  disturbance.  These  mental  disturbances  after  the 
epileptic  attacks  occur  very  much  more  frequently  than  the 
mental  epileptic  equivalent.  This  postepileptic  condition  may 
be  characterized  by  confusion,  during  w^hich  the  patient  speaks 
disconnectedly,  does  not  seem  to  have  a  clear  insight  into  his 
surroundings,  acts  peculiarly,  cannot  control  himself,  and  does 
not  seem  to  realize  the  demands  made  by  his  surroundings. 
This  state  of  confusion  may  last  a  few  minutes,  and  rarely  longer 
than  an  hour.  It  passes  off  somewhat  quickly,  and  the  patient 
has  no  recollection  of  w^hat  has  occurred  during  the  attack.  In 
other  cases  after  one  or  several  attacks  active  delirium,  develops. 
This  delirious  condition  may  last  for  several  hours  or  days,  and 
during  this  time  the  patient  may  be  violently  excited  and  very 
destructive;  he  does  not  seem  to  feel  injuries  or  pain.  These 
patients  frequently  act  as  if  they  were  being  driven  by  some 
irresistible  power;  at  other  times  their  actions  seem  to  be  the 
result  of  hallucinations  and  delusions.  Occasionally,  instead  of 
maniacal  excitement,  states  of  depression  or  anxiety,  with  terrify- 
ing hallucinations,  may  occur.  In  the  maniacal  stage  the  patient 
may  commit  crimes,  and  in  the  depressed  stage  he  may  attempt 
self-destruction. 

The  symptomatic  and  Jacksonian  epileptic  seizures  require  no 
special  description,  being  merely  evidences  of  a  general  disease 
or  of  local  irritation  of  the  brain. 


EPILEPSY    (falling   SICKNESS)  565 

Between  the  attacks  the  mental  and  physical  condition  of  the 
patient  is  often  normal.  In  many  cases  stigmata  of  degenera- 
tion are  present.  In  some  individuals,  even  between  attacks, 
peculiarities  of  disposition  exist.  Epileptics  are  often  of  an 
excitable,  irritable,  and  suspicious  temperament.  In  some 
there  are  present  a  diminution  of  intelligence  and  weakness  of 
memory. 

The  forms  of  epilepsy  that  develop  early  in  childhood  are 
often  combined  with  imbecility  or  idiocy,  and  those  in  whom  the 
mind  may  have  been  normal  at  first,  may  later,  as  the  result 
of  repeated  and  severe  attacks,  develop  mental  weakness. 

Course. ^The  disease  usually  begins  in  early  life,  and  the 
first  attack  can  generally  be  attributed  to  some  definite  cause, 
but  this  is  not  always  the  case.  Between  the  first  and  the  second 
attack  there  usually  occurs  a  somewhat  long  interval,  succeeding 
attacks  appearing  at  shorter  intervals  and  usually  without 
ascertainable  cause.  In  some  cases  there  is  a  distinct  aura 
before  the  attacks,  but  in  many  there  is  no  warning,  the  attacks 
coming  on  suddenly,  and  lasting  for  a  variable  length  of  time. 
They  are  followed  by  mental  confusion  and  sleep,  although  in 
some  cases  the  mind  of  the  patient  is  comparatively  clear 
immediately  after  the  attack.  The  milder  the  attack,  the  more 
apt  is  the  patient  to  be  mentally  clear  shortly  after. 

Attacks  occur  more  frequently  during  the  day,  but  in  some 
patients  the  attacks  occur  only  at  night,  and  if  they  are  not 
very  severe,  and  if  the  patient  sleeps  alone,  they  may  remain 
undiscovered. 

Individuals  may  have  both  major  and  minor  seizures,  or 
suffer  only  from  the  major  or  the  minor  attacks.  In  some  pa- 
tients the  seizures  occur  with  considerable  frequency  for  a  long 
time,  and  then  a  long  interval  intervenes  during  which  the  patient 
is  free  from  seizures.  Sometimes  attacks  occur  with  a  certain 
regularity,  or  the  patient  is  able  to  foretell  by  his  feelings,  one 
or  two  days  previously,  that  he  is  about  to  have  a  seizure. 

Acute  febrile  diseases,  injuries,  operations,  etc.,  often  seem 
to  inhibit  the  occurrence  of  the  attacks,  but  shortly  after  the 
acute  illness  is  over  they  reappear.  In  some  few  cases  an  acute 
illness  has  seemed  to  effect  a  cure. 


566  MANUAL   OF   NERVOUS   DISEASES 

This  disease  runs  a  prolonged  course,  with  more  or  less  frequent 
repetition  of  attacks,  which  occur  at  indefinite  intervals.  The 
attacks  may  be  followed  by  peculiar  mental  states  and  transitory 
or  permanent  physical  disability,  which  is  often,  sooner  or  later, 
attended  by  permanent  physical  and  mental  degeneration. 

Prognosis. — The  prognosis  as  to  complete  recovery  is,  un- 
fortunately, not  good.  In  a  few  cases  in  which  a  definite 
causative  condition  can  be  discovered  and  removed,  the  prog- 
nosis is  good.  In  those  cases  in  which  no  cause  can  be  dis- 
covered there  are  between  5  and  10  per  cent,  of  recoveries. 

The  cases  associated  with  acquired  or  congenital  mental 
weakness  present  the  most  unfavorable  prognosis.  The  longer 
the  disease  has  lasted,  the  less  chance  there  is  for  recovery  to 
take  place.  The  earlier  in  life  the  disease  manifests  itself,  the 
graver  is  the  prognosis.  The  probability  of  recovery  is  not  so 
good  in  minor  epilepsy  as  it  is  in  the  major  form.  The  danger 
to  life  in  individual  attacks  is  not  great,  provided  the  patient  is 
properly  protected.  Owing  to  the  fact,  however,  that  these 
seizures  may  occur  at  any  time  and  under  any  conditions, 
accidental  death  may  occur  during  an  attack.  These  patients 
should  be  advised  to  be  very  cautious  about  exposing  themselves 
to  danger. 

From  25  to  50  per  cent,  of  patients  who  develop  the  status 
epilepticus  die  during  this  state.  A  large  number  of  individuals 
who  suffer  from  epilepsy  die  of  intercurrent  conditions  before 
they  reach  the  thirty-fifth  or  the  fortieth  year. 

Diagnosis. — ^The  diagnosis  of  epilepsy  is  to  be  made  only 
after  a  careful  consideration  of  the  history  of  repeated  attacks  in 
which  disturbance  or  loss  of  consciousness  occurs.  Epilepsy 
must  be  differentiated  from  simple  fainting  spells,  from  con- 
vulsive seizures  due  to  a  toxic  condition,  such  as  occurs  in  kidney 
diseases,  gastro-intestinal  intoxication,  etc.,  from  Meniere's 
disease,  and  from  hysteria.  The  diagnosis  must  never  be  made 
from  the  occurrence  of  a  single  attack,  and  it  is  only  the  repetition 
of  attacks,  with  or  without  apparent  cause,  that  justifies  the 
diagnosis.  Repeated  convulsive  seizures  or  peculiar  mental 
states  in  children,  when  accompanied  by  evidences  of  mental 
degeneracy,  usually  mean  the  existence  of  epilepsy.     Attacks 


EPILEPSY    (falling    SICKNESS)  567 

of  petit  mal,  beginning  in  early  childhood,  generally  present 
no  difficulties  in  the  diagnosis.  The  differentiation  between 
epilepsy  and  symptomatic  convulsions  depends  entirely  upon 
the  examination,  which  will  reveal  the  cause  of  the  con\Tilsive 
seizures.  The  differentiation  between  epilepsy  and  Meniere's 
disease  is  made  by  the  constancy  of  the  tinnitus  aurium,  the 
disturbance  of  hearing,  and  the  effect  of  sudden  changes  in 
position  in  Meniere's  disease. 

From  simple  fainting  spells  epilepsy  can  usually  be  very 
readily  diagnosed:  in  fainting  spells  the  face  becomes  pale,  the 
heart  action  feeble,  and  the  reflexes  are  not  lost;  the  patient  does 
not  injure  himself  in  falling,  there  are  no  con^mlsions,  and  the 
seizure  is  generally  brought  on  by  a  sudden  mental  impression 
or  a  sudden  change  of  position:  in  epilepsy  the  face  is  cynanotic 
or  flushed,  the  pulse  full,  convulsive  seizures  or  peculiar  mental 
states  exist,  and  the  seizure  comes  on  without  cause  or  follows 
a  definite  aura;  the  patient  may  injure  himself  or  lose  control 
of  the  bowel  and  bladder,  and  the  reflexes,  particularly  the 
pupillary  reflexes,  are  lost. 

The  dift'erentiation  between  hysteric  attacks  and  epileptic 
attacks  may  in  some  cases  give  rise  to  considerable  difficulty. 
The  differentiation  is  made  by  a  careful  inquiry  into  the  facts 
presented  on  page  568. 

Treatment. — Before  undertaking  the  treatment  of  a  person 
sufi'ering  with  epilepsy  it  is  most  important  to  make  a  careful 
and  thorough  examination  in  order  to  discover,  if  possible,  the 
presence  of  the  causes  of  the  attack.  Any  abnormalities 
or  diseases  which  are  found  should  be  carefully  considered 
and  receive  proper  treatment.  The  presence  of  intestinal 
parasites,  of  nasal  disease,  sinus  disease,  unerupted  or  carious 
teeth,  phimosis,  gastro-intestinal  disorders,  toxemia,  pregnancy, 
scars,  etc.,  should  be  carefully  examined  for,  and  the  patient 
brought  into  as  good  a  physical  condition  as  possible.  The 
correction  of  general  diseased  conditions  or  of  abnormalities,  the 
elimination  of  toxic  substances,  such  as  alcohol,  tobacco,  etc., 
may  in  some  few  cases  result  in  bringing  about  cessation  or  cure 
of  the  attacks;  even  if  this  does  not  take  place,  it  may  help  in 
the  symptomatic  treatment  of  the  disease. 


568 


MANUAL   OF   NERVOUS  DISEASES 


Cause: 
Age: 

Sex: 

Conditions     under 
which    attacks 
occur: 

Aura: 

Abnormal     move- 
ments: 

Character  of  move- 
ments: 

Duration : 


Appearance: 
Breathing: 


Injury.: 

Deep  reflexes: 

Pupillary  reflexes: 

Bowel  and  bladder 
reflexes: 

Following  attacks: 


Effects  of  sugges- 
tion: 
Temperature : 


Epilepsy. 


Frequently  none. 

Usually  begins  before  the 
twentieth  year,  and  fre- 
quently in  early  child- 
hood. 

Slightly  more  frequent  in 
males. 

Occur  under  any  condi- 
tion. 

Always  the  same. 

Tonic,  followed  by  clonic, 

spasms. 
Purposeless. 


Tonic  state  for  a  few  sec- 
onds, clonic  state  for  a 
few  moments. 

Cyanotic,  followed  by  a 
flushed  appearance  of 
the  face. 

No  respiration  during  tonic 
states,  but  followed  by 
stertorous  breathing,  and 
gradually  becoming  nor- 
mal. 

Bloody  froth  and  saliva 
dribbling  from  mouth. 

Biting  the  tongue,  cuts, 
bruises,  fractures,  etc. 

Almost  always  lost  during 
attack  and  shortly  after. 

Reaction  practically  al- 
ways lost. 

Frequently  incontinence 
of  urine  and  feces  at  the 
onset  or  during  the  at- 
tack. 

Patient  recovers  rapidly, 
is  confused  for  a  short 
time,  or  sleeps  for  sev- 
eral hours. 

None. 

Increased  in  severe  attacks. 


Hysteria. 


Generall}'^  some  emotional 
condition. 

Usually  manifests  itself  for 
the  first  time  after  the 
fifteenth  year,  but  may 
occur  earlier. 

Much  more  frequent  in 
females. 

Attacks  usually  occur  only 
when  the  individual  is 
under  observation. 

Variable. 

Clonic,  followed  by  tonic, 
convulsions. 

Usually  result  in  some  def- 
inite purposive  actions, 
such  as  pulling  the  hair, 
scratching,  biting,  etc. 

Tonic  and  clonic  states  al- 
ternating, lasting  from  a 
few  moments  to  several 
hours. 

Never  cyanotic,  may  be 
pale  or  flushed. 

No  disturbance,  at  times 
noisy,  shallow,  rapid,  or 
slow. 


Usually  not  present. 

At  times  scratching  of  the 
hands  or  face  or  injury  to 
others,  rarely  to  self. 

Generally  increased. 

Practically  never  lost. 

Practically  no  disturbance; 
the  passage  of  a  large 
quantity  of  pale  urine 
after  an  attack. 

Rarely  sleeps  except  as  the 
result  of  exhaustion  after 
a  long  and  severe  attack; 
usually  recovers  slowly. 

Frequently  reacts  to  sug- 
gestion during  the  attack. 

Practically  no  increase. 


EPILEPSY    (falling    SICKNESS)  569 

The  patient  should  be  placed  on  a  light  diet;  all  irritating 
foods,  such  as  spices,  strong  coffee,  alcoholic  liquors,  heavy 
pastries,  improperly  cooked  food,  etc.,  should  be  avoided,  and 
the  diet  should  consist  principally  of  vegetables,  milk,  meat  in 
small  quantities,  fruits,  light  desserts,  the  white  meat  of  fowl, 
fish,  etc.  It  is  better  to  eat  frequently,  taking  small  quantities 
at  a  time.  Salt  should  be  used  as  sparingly  as  possible,  as  it  has 
been  found  that  when  salt  is  restricted  less  bromid  is  required 
to  control  the  attacks. 

Exercise  may  be  allowed  in  moderation,  but  fatigue,  worry, 
mental  overstrain,  and  excitement  are  to  be  carefully  avoided. 
The  patient  should  engage  in  an  occupation  that  does  not  expose 
him  to  danger;  thus  he  should  avoid  occupations  that  require 
him  to  ascend  ladders  or  to  work  on  scaffolds,  or  any  employ- 
ment that  requires  him  to  be  near  moving  engines  or  machinery, 
or  close  to  water  or  to  fire,  etc.  He  should  not  follow  any  voca- 
tion that  requires  constant  mental  alertness  the  lapse  of  which 
might  endanger  his  own  life  or  the  lives  of  others,  such  as  that 
of  railroad  employee,  watchman,  etc. 

Climate. — Extremely  hot  or  cold  climates  should  be  avoided, 
and  the  patient  should  guard  against  unduly  exposing  himself  to 
extremes  of  heat  and  cold. 

Hydrotherapy. — Warm  baths,  followed  by  cold  sponges, 
keeping  the  skin  in  good  condition  and  promoting  the  general 
health,  do  good. 

Cases  in  which  the  attacks  are  associated  with  or  followed  by 
marked  mental  disturbances  are  better  protected  in  institu- 
tions. 

Treatment  of  the  Patient  During  the  Epileptic  Attack. — In  some 
cases  that  are  preceded  by  aura  the  attack  may  be  aborted  at 
times  by  the  inhalation  of  amyl  nitrite,  the  administration  of  a 
dose  of  aromatic  spirits  of  ammonia,  the  application  of  a  ligature 
about  the  extremity  in  which  the  aura  is  perceived,  or  by  the 
patient  exercising  violently.  During  an  attack  there  is  very 
little  that  can  be  done,  except  to  see  that  the  patient  is  placed  in 
such  a  position  that  he  cannot  injure  himself;  all  tight  clothing 
should  be  loosened,  and,  if  possible,  a  cork  or  some  cloth-covered 
object  is  to  be  placed  between  the  teeth,  so  as  to  prevent  the 


570  MANUAL   OF   NERVOUS   DISEASES. 

patient  from  biting  his  tongue.  As  the  attack  subsides  the 
patient  should  be  placed  in  a  comfortable  position,  so  that  he 
may  go  to  sleep;  no  effort  should  be  made  to  awaken  him.  If 
the  patient  has  a  succession  of  attacks,  it  is  advisable  to  ad- 
minister purgatives,  and  if  the  seizures  follow  one  another,  or 
if  there  is  no  return  of  consciousness,  croton  oil,  one  or  two  drops 
in  a  small  amount  of  olive  oil,  should  be  placed  upon  the  back 
of  the  tongue.  Chloral  hydrate,  in  doses  of  from  one-half  to 
a  dram  and  a  half,  with  or  without  bromid,  should  be  given  by 
rectum.  Hyoscin  and  morphin  may  be  given  hypodermically. 
If  these  drugs  do  not  control  the  seizures,  blood-letting  may  be 
tried  or  chloroform  inhalations  given.  This  last  is  generally 
successful  in  bringing  the  convulsions  to  an  end,  at  least  tem- 
porarily; if,  after  the  prolonged  use  of  chloroform,  the  convulsions 
again  reappear,  a  fatal  termination  may  be  expected. 

Treatment  of  the  Patient  Between  Attacks. — In  most  cases, 
after  all  that  is  possible  has  been  done  to  treat  the  probable 
cause  and  to  regulate  the  patient's  life,  it  is  necessary  to  give 
medicaments  to  control  the  number  and  severity  of  the  seizures. 
In  those  cases  in  which  the  attacks  occur  very  infrequently, 
e.  g.,  one  convulsion  in  one  or  two  years,  drugs  are  not  absolutely 
necessary. 

The  most  useful  and  effective  of  all  remedies  are  the  bromid 
preparations.  Any  one  of  the  bromid  salts  may  be  used, 
potassium  bromid  seeming  to  be  somewhat  superior  to  the  other 
salts  in  its  effect  upon  this  disease.  It  is  advisable  to  begin  with 
small  doses  of  the  bromid  salts,  given  three  times  a  day,  gradually 
increasing  the  dose  until  sufficiently  large  doses  are  given  to 
control  the  convulsions.  It  is  advisable  to  vary  the  bromid 
salts  from  time  to  time,  and  they  may  with  advantage  be  com- 
bined with  a  bitter  tonic,  given  well  diluted,  as  they  seem  less 
likely  then  to  cause  gastric  disturbances.  Such  a  combination 
is  the  following:  Potassium  bromid,  15  grains;  tincture  of 
gentian  compound,  J  dram;  water,  a  sufficient  quantity,  given 
several  times  a  day. 

It  is  well  to  try  the  different  salts  of  the  bromids  in  different 
individuals,  since  some  bear  one  salt  better  than  another.  The 
bromid  may  be  given  in  one  dose  or  in  several  doses,  or  one  at 


EPILEPSY  (falling  sickness)  57 1 

night  and  one  in  the  morning,  or  two  small  doses  during  the  day 
and  a  large  dose  at  night — one  must  be  guided  by  the  results 
and  the  surroundings  of  the  patient  as  to  the  best  time  to  give 
the  drug  and  the  size  of  the  dose.  If  the  bromids  are  not  well 
borne,  bromotone,  in  5-grain  capsules,  may  be  given.  The 
bromids  must  be  given  in  sufficiently  large  doses  to  control  the 
seizures — the  smallest  doses  that  will  control  them  should  be 
continued  for  a  prolonged  period,  and  be  discontinued  only  in 
case  of  necessity,  such  as  the  occurrence  of  some  acute  illness, 
extreme  exhaustion  associated  with  mental  dulness,  physical 
weakness,  gastric  disturbances,  etc.  After  the  continuous 
administration  of  bromids,  if  no  attack  has  occurred  for  two 
years,  their  administration  may  be  discontinued.  In  some 
cases  the  bromid  may  entirely  suppress  the  attacks,  but  in  the 
greater  number  it  merely  relieves  them,  and  in  some,  especially 
those  of  the  petit  mal  type,  it  seems  to  have  no  effect.  In  case 
the  bromids  alone  do  not  prove  effective,  they  may  be  combined 
with  the  fluidextract  of  belladonna,  or,  in  other  cases,  with 
tincture  of  digitalis.  In  some  cases  atropin  seems  to  control 
the  attacks.  This  last  should  be  administered  first  in  small 
doses,  gradually  increasing  the  dose  until  the  physiologic  effect  is 
reached.  Bromipin,  which  is  potassium  bromid  combined  with 
oil  of  sesame,  one  dram  equaling  thirty  grains  of  potassium 
bromid,  although  possessing  a  very  disagreeable  taste,  seems  to 
be  valuable,  owing  to  its  nutritive  properties;  it  rarely  causes 
acne.  In  some  cases  chloral  hydrate  in  5-grain  doses  may 
temporarily  be  added  to  the  bromid  preparations,  but  if  its  use 
is  long  continued  it  produces  cardiac  weakness. 

Calcium  lactate  and  parathyroid  extract  in  some  cases  seem 
to  exercise  a  favorable  effect,  especially  in  the  attacks  of  petit 
mal.  Antipyrin,  in  doses  of  ten  or  fifteen  grains  two  or  three 
times  a  day,  also  seems  to  have  effect  in  controlling  the  con\Til- 
sions.  Borax,  ten  to  tw^enty  grains,  taken  after  meals,  is  some- 
times effective  when  the  bromid  preparations  fail;  this  drug  can- 
not be  taken  in  large  doses  for  any  length  of  time  as  it  produces 
cutaneous  eruptions  of  an  eczematous  nature. 

Surgical  Treatment. — ^The  operative  treatment  of  epilepsy  is 
justifiable  only  when  there  is  distinct  evidence  of  the  existence 


572  MANUAL  OF  NERVOUS  DISEASES 

of  some  localized  cerebral  irritative  area.  This  is  especially 
the  case  if,  after  injury,  there  is  evidence  of  a  localized  cerebral 
irritation,  or  if  symptoms  point  to  the  existence  of  a  localized 
cerebral  lesion  that  is  acting  as  an  irritant,  and  which  is  so 
situated  as  to  be  readily  accessible  to  surgical  intervention. 

Scars  or  cicatrices  upon  the  skin,  or  in  some  other  portion  of 
the  body,  producing  epileptic  seizures  by  acting  as  an  irritant, 
should  be  carefully  sought  for  and  promptly  removed.  After 
operative  procedures  systematic  medical  and  dietetic  treat- 
ment should  be  continued  for  a  long  time. 

Operative  procedures  are  not  justifiable  in  epilepsy  unless 
there  are  definite  evidences  of  cerebral  or  reflex  irritation. 

MYOCLONUS   EPILEPSY   OF  UNVERRICHT 

This  disease  is  an  exceedingly  rare  affection,  in  which  epilepsy 
is  present,  combined  with  the  occurrence  of  tonic  or  clonic 
spasms  in  different  muscles,  which  may  or  may  not  be  painful. 
The  disease  is  usually  seen  to  occur  in  several  members  of  the 
same  family,  generally  beginning  in  early  childhood  as  a  nocturnal 
epilepsy.  The  attacks  occur  at  first  infrequently,  and  later  at 
shorter  intervals.  Sometimes,  instead  of  an  epileptic  attack, 
the  patient  awakens  with  painful  tonic  or  clonic  spasms  in  the 
extremities.  The  disease  is  chronic  in  its  course,  and  later  on, 
if  the  attacks  increase  in  frequency,  a  stage  is  reached  in  which 
the  tonic  or  clonic  spasms  of  the  extremities  are  more  or  less 
persistently  present. 

Tremor,  with  fibrillary  fascicular  contractions  of  the  muscles, 
at  first  limited  to  the  extremities,  and  gradually  extending  to 
involve  all  the  voluntary  muscles  of  the  body,  occurs  sooner  or 
later.  The  tremoi  varies  from  time  to  time,  and  alternates  with 
lightning-like  contractions  in  the  various  muscles.  The  tremor 
ceases  during  sleep,  and  is  increased  upon  exercise  or  excitement. 
The  knee-jerks  are  exaggerated.  After  the  disease  has  existed 
for  some  years  gradual  mental  disturbances,  characterized  by 
dementia,  depression,  or  excitement,  occur. 

The  prognosis  is  very  unfavorable;  after  the  disease  has  run 
a  prolonged  course  the  individual  dies  of  general  asthenia. 


PARAMYOCLONUS   MULTIPLEX  573 

PARAMYOCLONUS   MULTIPLEX 

This  affection  is  characterized  by  clonic  contractions,  affecting 
mainly  the  muscles  of  the  trunk  and  the  proximal  portions  of 
the  extremities.  The  contractions  occur  in  paroxysms,  are 
usually  bilateral,  and  affect  symmetrically  situated  muscles. 
As  many  as  from  60  to  100  contractions  a  minute  may  occur, 
the  intervals  between  the  paroxysms  being  of  varying  dura- 
tion. 

Etiology. — The  cause  of  the  disease  is  in  doubt.  It  occurs 
more  frequently  in  males  than  in  females,  and  generally  appears 
in  adult  life.  It  may  follow  fright,  anxiety,  overexertion, 
trauma,  etc. 

Pathology. — Friedreich  and  others  believe  this  neurosis  to  be 
due  to  an  irritation  of  the  nerve-cells  of  the  anterior  horn  of  the 
spinal  cord.  Similar  symptoms  have  been  observed  in  auto- 
intoxications. 

Symptoms. — This  disease  is  characterized  by  the  occurrence  of 
bilateral,  symmetrically  situated  contractions  of  muscles.  These 
spasmodic  contractions  are  limited  to  the  muscles  of  the  trunk, 
the  proximal  portions  of  the  extremities,  and  at  times  the  dia- 
phragm. In  no  case  have  the  muscles  of  the  forearms  and  hands 
or  the  legs  and  feet  been  affected. 

The  spasmodic  paroxysms  occur  at  intervals  varying  from  a 
few  minutes  to  days  or  wxeks.  During  a  paroxysm  the  muscular 
contractions  vary  in  number  from  50  to  over  100.  The  paroxysm 
may  last  from  a  half -minute  to  several  minutes.  The  severity 
of  the  muscle  contractions  varies  in  different  individuals  and 
at  different  times:  in  some  cases  they  are  so  violent  that  the 
individual's  body  is  thrown  about;  in  other  cases  they  are  so 
slight  that  the  movements  of  the  limbs  are  hardly  perceptible, 
only  fascicular  twitchings  of  the  muscles  being  evident. 

The  tendon  reflexes  are  usually  increased.  There  is  no  dis- 
turbance of  sensation,  and  voluntary  movements  are,  as  a  rule, 
unaffected.  Spasmodic  seizures  may  often  be  brought  about 
by  a  tap  upon  the  patellar  tendon  or  by  irritation  of  the  skin. 
Excitement  and  emotional  disturbance  increase  the  tendency  to 
seizures;   distraction  and  occupation  decrease  this  tendency. 


574  MANUAL   OF   NERVOUS  DISEASES 

In  some  cases  fibrillary  tremor  of  the  affected  muscles  is  present 
during  the  intervals  between  attacks. 

The  prognosis,  in  the  majority  of  cases,  is  good,  as  these 
patients  recover  rapidly  under  proper  treatment.  Relapses 
are  frequent. 

Diagnosis. — This  disease  must  be  differentiated  from  chorea, 
hysteria,  epilepsy,  tic,  etc.  From  chorea  the  disease  is  differ- 
entiated by  the  fact  that  in  chorea  the  spasmodic  movements 
are  not  symmetrically  bilateral,  and  that  they  affect  the  distal 
portions  of  the  extremities  or  the  face  as  frequently  as  they  do 
the  proximal  portions;  moreover,  the  muscle  contractions  do 
not  occur  in  definite  paroxysms,  but  occur  irregularly  and  un- 
expectedly. Paramyoclonus '  multiplex  is  differentiated  from 
hysteria  by  the  fact  that  it  is  limited  to  paroxysmal  clonic 
contractions  of  the  muscles  of  the  trunk  and  proximal  portion 
of  the  extremities,  which  can  frequently  be  brought  on  by 
tapping  the  knee-tendon  or  by  inducing  irritation  of  the  skin; 
in  hysteria  the  spasmodic  seizures  are  either  more  diffuse  or 
more  limited  in  extent,  vary  from  time  to  time,  and  are  not 
brought  on  by  tapping  of  the  knee-tendon  or  irritation  of  the 
skin;  in  addition,  there  are  usually  many  other  symptoms  of  a 
sensory  or  a  mental  nature. 

From  epilepsy  this  disease  is  differentiated  by  the  fact  that 
there  is  no  disturbance  of  consciousness,  and  that  the  spasmodic 
movements  are  limited  to  the  proximal  portions  of  the  limbs 
and  the  trunk. 

From  tic  it  is  differentiated  by  the  fact  that  the  movements 
in  the  tics  are  purposive  in  character,  and  very  frequently  involve 
the  face,  and  when  they  involve  the  extremities,  are  very  apt  to 
affect  the  distal  portions,  and  that  the  tics  are  not  brought  on 
by  tapping  of  the  knee-tendons  or  by  irritation  of  the  skin. 

Treatment. — The  administration  of  sedatives,  such  as  bromid 
of  potassium,  chloral,  etc.,  has  a  quieting  effect,  and  produces 
a  temporary  improvement.  Tonics,  with  general  up-building 
of  the  patient  by  massage  and  hydrotherapy,  are  to  be  tried. 
Galvanism  applied  to  the  spine  seems  to  be  of  some  benefit. 


DISEASES  DUE  TO  PERVERSION  OF  SECRE- 
TIONS OF  THE  DUCTLESS  GLANDS 

EXOPHTHALMIC  GOITER  (BASEDOW'S  OR  GRAVES' 

DISEASE) 

Etiology. — A  neuropathic  heredity  may  be  traced  in  many  of 
the  affected  individuals.  The  disease  occurs  more  frequently 
in  women  than  in  men,  and  develops  more  often  between  the 
twentieth  and  the  fortieth  year,  but  may  appear  much  earlier 
or  later.  Neuropathic  heredity  manifests  itself  very  often  as  a 
tendency  to  vasomotor  neurosis  in  other  members  of  the  family, 
and  as  nervousness  in  the  individual  sometimes  long  before  the 
onset  of  the  disease. 

In  a  predisposed  person  exophthalmic  goiter  may  occur 
without  any  other  direct  cause.  In  many  cases  the  disease  is 
preceded  by  emotional  excitement,  worry,  injury, .  physical 
exhaustion,  pregnancy  or  difhcult  labor,  infectious  disease, 
syphilis,  chronic  intoxication,  etc. 

Pathology. — ^At  the  present  time  there  is  still  a  difference  of 
opinion  as  to  the  primary  cause  of  this  disease.  Some  investi- 
gators believe  that  the  primary  changes  are  in  the  sympathetic 
or  central  nervous  system,  and  that  a  secondary  disturbance 
in  the  circulation  of  the  thyroid  gland  occurs,  with  an  increased 
formation  of  its  secretions,  and  that,  as  the  result  of  the  action 
of  these  substances,  many  of  the  secondary  symptoms  of  this 
disease  develop.  On  the  other  hand,  there  are  many  who  be- 
lieve that  the  primary  disease  affects  the  thyroid  gland;  that 
there  is  an  increase  in  the  secretions  of  this  gland,  and  that,  as 
the  result  of  this  toxic  substance  entering  the  circulation,  many 
of  the  nervous  and  secondary  symptoms  occur.     Careful  ex- 

575 


576  MA.NUAL   OF  NERVOUS   DISEASES 

amination  of  cases  of  exophthalmic  goiter  shows  wide-spread 
changes  in  the  thyroid  and  the  thymus  gland,  the  cervical 
sympathetic,  the  brain,  the  cranial  nerves,  and  the  medulla.  In 
the  thyroid  gland  the  changes  vary  from  a  simple  congestion 
to  a  marked  hypertrophy  of  part  or  of  the  entire  gland. 

The  colloidal  substance  is  usually  diminished  in  quantity; 
the  vessels  are  dilated;  the  connective  tissue  is  generally  de- 
veloped to  an  abnormal  drgree ;  the  lymph-spaces  are  obliterated, 
and  there  is  a  hyperplasia  of  the  parenchymatous  tissue.  Very 
often  a  hyperplasia  or  an  abnormal  persistence  of  the  thymus 
gland  is  present.  Degenerative  lesions  have  been  found  in  the 
brain,  in  the  nuclei  of  the  cranial  nerves,  and  in  the  cervical 
sympathetic. 

Symptoms. — ^Tachycardia  is  one  of  the  most  constant  and 
one  of  the  earliest  symptoms  of  this  disease.  It  occurs  in  practi- 
cally every  case,  the  pulse  varying  in  frequency  between  loo  and 
200  a  minute.  It  is  generally  small  and  soft,  averaging  about 
120  a  minute.  The  arteries,  especially  the  carotids,  pulsate 
strongly  and  visibly;  the  increased  pulse-rate  is  constantly 
present.  In  addition,  as  the  result  of  the  muscular  exertion  or 
emotional  disturbance,  attacks  of  cardiac  palpitation  occur  in 
which  the  rate  is  increased,  and  at  times  arhythmia  develops. 

Precordial  pain  is  frequently  present.  On  physical  examina- 
tion the  heart  often  shows  no  abnormalities,  although  some- 
times a  systolic  murmur  is  present  at  the  base.  The  heart  is 
often  enlarged,  and  in  advanced  stages  it  becomes  dilated,  with 
the  development  of  a  mitral  insufficiency. 

Enlargement  of  the  thyroid  gland,  which  may  be  limited  to 
one  lobe  or  affect  the  entire  gland,  occurs  in  many  cases.  The 
enlarged  thyroid  (goiter)  is  soft  and  pulsating;  the  superficial 
veins  are  usually  dilated;  a,  marked  thrill  can  sometimes  be 
perceived  by  the  hand  placed  above  or  over  the  thyroid.  A 
systolic  bruit  can  often  be  heard  an  auscultation.  The  goiter 
is  not  painful.  The  degree  of  swelling  varies  from  time  to  time. 
When  increase  in  the  size  of  the  thyroid  occurs  rapidly,  it  may 
produce  symptoms  of  compression  and  interfere  with  breathing 
and  with  deglutition. 

Many  cases  of  exophthalmic  goiter  occur  in  which  there  is  little 


EXOPHTHALMIC    GOITER  577 

or  no  perceptible  enlargement  of  the  thyroid.  It  is  important 
to  remember  that  the  thyroid  may  be  diseased  even  if  it  is  not 
enlarged. 

Exophthalmos,  which  is  usually  bilateral,  but  which  may 
be  unilateral,  is  also  a  common  symptom.  Early  in  the  disease 
it  may  be  limited  to  one  eye,  the  left  one  being  particularly 
affected.  Throughout  the  disease  it  may  be  more  pronounced 
on  one  side  than  on  the  other.  The  degree  of  exophthalmos 
varies  in  different  cases — sometimes  it  is  very  slight,  and  in 


Fig.  158. — Exophthalmic  goiter  (case  of  Dr.  Randolph  Winslow). 

other  cases  it  is  so  marked  that  the  eyelids  cannot  be  completely 
closed,  and  the  insertions  of  the  eye  muscles  are  visible  (Fig. 

158). 

Tremor  is  almost  always  present.  It  is  rapid  and  vibratory, 
from  8  to  10  oscillations  occurring  to  the  second.  It  is  in- 
creased by  movement  and  by  emotional  disturbances.  It  is 
sometimes  limited  to  the  extremities,  and  at  times  involves  the 
trunk.  It  does  not  necessarily  persist  throughout  the  whole 
course  of  the  disease. 


578  MANUAL   OF   NERVOUS   DISEASES 

Trophic,  vasomotor,  and  secretory  disorders  also  occur  in 
nearly  all  cases.  Discoloration  of  the  skin,  urticaria,  pigmenta- 
tion of  the  margins  of  the  eyelids,  falling  out  and  turning  gray 
of  the  hair,  swelling  of  the  eyelids,  hemorrhages  from  the  uterus 
and  nose,  ecchymosis,  etc.,  sometimes  occur  early,  and  generally 
appear  at  some  time  during  the  course  of  the  disease.  Dermo- 
graphia  occurs  very  frequently.  Flushes  of  heat  and  cold  and 
slight  elevation  of  temperature  are  also  commonly  observed. 
Hyperidrosis  is  a  very  frequent  symptom,  being  absent  in  only 
a  few  cases;  the  sweating  may  be  partial,  and  be  limited  to  the 
hands  and  feet  or  head,  or  it  may  be  general ;  it  varies  in  degree 
— in  some  cases  it  is  but  slight,  and  in  others  it  is  so  extensive  as 
to  necessitate  frequent  change  of  clothing.  The  secretion  of 
urine  is  often  increased;  albuminuria  and  glycosuria  occur  but 
rarely. 

Digestive  disturbances  are  frequently  complained  of.  Loss 
of  appetite,  dryness  of  the  mouth  and  pharynx,  and  attacks  of 
vomiting  may  occur,  the  last  giving  rise  to  much  distress. 
Attacks  of  diarrhea  in  which  the  stools  are  sudden,  frequent, 
and  usually  painless,  from  four  to  ten  or  more  occurring  in  a  day, 
and  not  dependent  on  the  diet,  are  common.  These  diarrheas 
are  more  frequent  upon  exertion  or  after  emotional  excitement, 
and  generally  contribute  greatly  to  the  patient's  exhaustion. 

The  general  nutrition  of  the  patient  is  often  disturbed. 
There  is  a  loss  of  weight,  which  may  be  slight,  but  in  some  cases 
is  very  marked,  and  occurs  in  spite  of  the  taking  of  an  increased 
amount  of  food. 

Physical  weakness,  varying  from  a  slight  degree  to  one  in 
which  the  patient  is  almost  unable  to  move,  sometimes  occurs. 
This  physical  weakness  is  due  partly  to  the  emaciation,  but 
actual  motor  weakness  which  affects  chiefly  the  legs  also  exists. 
The  deep  reflexes  are  usually  unaltered,  but  may  be  increased  or 
decreased.  In  some  few  cases  attacks  of  dyspnea  occur,  and  a 
dry,  spasmodic  cough  is  sometimes  complained  of.  Irregular- 
ities and  disturbances  of  menstruation  may  be  present. 

The  mental  condition  of  an  individual  suffering  with  ex- 
ophthalmic goiter  is  rarely  normal.  These  individuals  are 
usually  restless,  irritable,  and  very  excitable.    The  emotional 


EXOPHTHALMIC    GOITER  579 

tone  is  most  variable:  the  patients  are  easily  confused,  very 
forgetful,  easily  embarrassed,  etc.  In  some  cases  marked 
psychoses,  such  as  acute  delirium,  melancholia,  excitement, 
hallucinations,  etc.,  develop,  but  these  are  not  at  all  common. 
Symptoms  of  exophthalmic  goiter  may  also  develop  during  the 
course  of  a  psychosis.  Sleep  is  usually  disturbed,  and  insomnia 
is  present  in  many  cases. 

Ocular  Symptoms. — The  ocular  movements  may  be  impaired 
by  the  exophthalmos,  but  true  paralysis  of  the  eye  muscles  is 
very  uncommon.  A  vibratory  tremor  of  the  eyeball  is  some- 
times noticed.  Ophthalmoscopic  examination  usually  reveals 
a  distinct  pulsation  of  the  retinal  arteries,  but  otherwise  there 
are  no  fundal  changes. 

Stellwag's  sign  may  be  present:  The  palpebral  aperture 
is  abnormally  wide,  even  when  there  is  no  exophthalmos,  and 
the  patient  does  not  wink  as  often  as  the  normal  individual. 

Von  Graefe's  sign  is  often  seen,  and  consists  of  an  inability  of 
the  eyelid  to  follow  the  movements  of  the  eyeball.  Thus  when 
the  globe  is  voluntarily  moved  upward  or  downward,  there  is 
a  delay  in  the  movements  of  the  eyelids  in  the  corresponding 
direction.  When  looking  downward,  the  superior  conjunctiva 
becomes  visible. 

Mobius^  Sign. — ^This  consists  of  a  difficulty  in  convergence, 
and  is  of  value  only  when  there  are  no  errors  of  refraction. 
This  sign  is  tested  for  by  having  the  patient  look  first  at  a  distance 
and  then  at  a  point  close  to  his  nose.  When  the  sign  is  present, 
only  one  eye  assumes  the  position  of  convergence  and  the  other 
deviates  downward. 

Course. — This  disease  is  usually  of  slow  onset,  but  may 
develop  acutely,  especially  after  violent  emotion.  In  many 
cases  there  exists,  for  some  time  before  the  onset  of  the  character- 
istic symptoms,  general  weakness,  fatigue,  and  loss  of  weight. 
Sometimes  before  the  diagnosis  can  be  made  a  stage  exists  in 
which  the  individual  presents  symptoms  of  a  neurasthenic  or  a 
hysteric  character. 

Cases  also  occur  in  which  some  of  the  leading  symptoms  are 
absent;  thus  forms  of  exophthalmic  goiter  occur  without  en- 
largement of  the  thyroid  or  without  the  exophthalmos — the 


580  MANUAL   OF   NERVOUS   DISEASES 

absence  of  one  of  these  symptoms  is  not  at  all  uncommon.  The 
disease  is  usually  a  protracted  one,  and  may  last  for  many  years, 
with  remissions  and  intermissions.  A  type  also  occurs  in  which 
the  development  of  the  disease  is  very  acute,  and  which  runs 
an  acute  course,  terminating  fatally  in  a  short  time,  or,  after  an 
acute  onset,  running  a  chronic  course. 

Prognosis. — The  prognosis  depends  upon  the  cardiac  condi- 
tion and  upon  the  state  of  nutrition.  Cases  that  are  of  acute 
development,  those  which  have  persisted  for  a  long  time,  and 
those  that  cannot  or  will  not  take  proper  treatment,  present  an 
unfavorable  outlook  as  regards  recovery.  In  those  cases  in 
which  the  general  nutrition  is  good  and  in  which  the  mental 
symptoms  are  not  very  severe;  in  which  the  pulse-rate  is  not 
excessively  fast,  and  in  which  the  individual  is  able  to  receive 
proper  treatment,  the  prognosis  is  hopeful,  at  least  for  improve- 
ment, if  not  for  complete  cure. 

There  is  always  danger  of  recurrence  taking  place  when 
unfavorable  conditions  are  present,  such  as  acute  illness,  over- 
exertion, undue  emotional  excitement,  pregnancy,  etc.  Death 
may  occur  from  uncontrollable  vomiting,  from  profuse  diarrhea, 
from  compression  of  the  trachea  by  the  goiter,  from  acute  cardiac 
dilatation,  etc.  The  rapidity  of  the  heart-beat  and  the  state  of 
the  general  nutrition  are  the  best  guides  as  to  the  gravity  of  the 
condition.  The  outlook  is  worse  where  the  loss  of  weight  is 
rapid  and  excessive  and  where  the  tachycardia  is  extreme. 

Diagnosis. — In  marked  cases  there  can  be  no  difl&culty  in 
recognizing  the  disease  from  the  presence  of  its  cardinal  symp- 
toms and  signs.  The  exophthalmos  should  always  lead  one  to 
think  of  retrobulbar  tumors,  hydrocephalus,  and  aneurysm. 
In  the  absence  of  exophthalmos  and  marked  enlargement  of  the 
thyroid  gland  this  disease  may  be  confused  with  neurasthenia 
and  hysteria.  Between  these  two  diseases  and  exophthalmic 
goiter  it  may  be  very  difficult  to  arrive  at  a  positive  conclusion 
as  to  the  correct  diagnosis.  In  exophthalmic  goiter,  in  addition 
to  the  tachycardia,  which  is  constant,  there  are  usually  present 
some  of  the  accessory  symptoms,  such  as  pigmentation  of  the 
skin,  ocular  disturbances,  dermographia,  vomiting,  diarrhea, 
tremor,  etc.    In  neurasthenia  or  hysteria  the  tachycardia  is 


EXOPHTHALMIC    GOITER  58 1 

not  SO  constant;  the  ocular  symptoms  occur  only  rarely;  the 
diarrhea  or  vomiting,  loss  of  weight,  etc.,  are  not  so  persistent, 
nor  do  they  have  so  serious  an  effect  upon  the  individual's 
general  condition  as  they  do  when  they  occur  in  exophthalmic 
goiter.  In  exophthalmic  goiter  the  mental  symptoms  are  more 
marked  and  more  constant  than  they  are  in  hysteric  patients. 
At  times  it  may  be  difhcult  to  differentiate  simple  goiter  pressing 
upon  the  trachea  and  cervical  sympathetic  ganglia,  giving  rise 
to  attacks  of  dyspnea,  hoarseness,  etc.,  occurring  in  a  nervous 
individual,  from  a  true  exophthalmic  goiter.  In  these  cases 
there  is  usually  an  absence  of  tremor,  the  exophthalmos  is  apt 
to  be  unilateral,  and  there  is  an  absence  of  diarrhea,  of  mental 
symptoms,  of  the  ocular  signs,  etc. 

Treatment. — It  is  most  important  to  place  the  patient  at 
absolute  rest.  Even  in  mild  or  moderately  severe  cases  the 
patient  should  be  placed  in  bed,  preferably  in  the  open  air  or 
in  a  large,  well- ventilated  room.  All  emotional  disturbances, 
worry,  and  excitement  should  be  guarded  against;  in  order  to 
accomplish  this  it  is  generally  necessary  to  remove  the  patient 
from  his  home.  Very  moderate  exercise  is  sometimes  permissible, 
but  fatigue  must  be  avoided.  The  diet  should  consist  of  easily 
digested  and  nourishing  food.  At  times  it  may  be  advisable  to 
place  these  patients  upon  a  diet  consisting  mainly  of  vegetable 
foods,  to  which  milk  and  cream  should  be  added  in  abundance. 
Coffee,  tea,  tobacco,  and  alcoholic  beverages  should  be  for- 
bidden. All  exciting  diversions  are  to  be  avoided,  and  sexual 
indulgence  is,  so  far  as  possible,  to  be  interdicted.  Mild 
hydropathic  treatment,  such  as  cool  packs,  cold  rubs,  tepid 
baths,  wet  packs,  etc.,  may  be  of  benefit  in  the  milder  cases. 
Residence  in  high  altitudes  seems  also  to  have  a  beneficial  re- 
sult. 

Electrotherapy. — Stable  galvanization  of  the  sympathetic 
often  has  a  good  effect.  An  electrode  (cathode),  about  one  inch 
in  diameter,  is  placed  on  the  side  of  the  neck  at  the  inner  margin 
of  the  sternomastoid  muscle,  below  the  angle  of  the  lowxr  jaw; 
the  other  electrode,  which  should  be  larger,  is  placed  on  the  side 
of  the  neck,  about  the  level  of  the  seventh  cervical  vertebra  and 
a  current  of  two  or  three  milliamperes  is  applied  for  several 


582  MANUAL   OF   NERVOUS   DISEASES 

minutes.  This  treatment  should  be  persisted  in  for  some  time. 
Care  should  be  taken  not  to  use  too  strong  a  current,  as  this 
may  aggravate  the  condition.  The  treatment  should  be  given 
daily. 

Good  results  have  also  been  obtained  by  the  administration 
of  thyroid  extract,  parathyroid  extract,  thyroidin,  and  the 
extract  of  other  glands;  benefit  has  also  been  derived  from  the 
administration  of  a  serum  prepared  by  Rogers  and  Beebe,  the 
antithyroid  serum  of  Moebius. 

Certain  drugs  may  be  helpful;  thus  beneficial  results  have  been 
obtained  from  the  administration  of  the  bromids,  iron,  and 
quinin,  especially  when  used  in  combination  with  belladonna 
or  ergot.  The  salicylates,  digitalis,  strophanthus,  atropin,  and 
the  iodids  must  be  used  with  great  caution.  The  bowels 
should  be  regulated  by  mild  purgatives.  Cold  compresses  or 
ice  packs  applied  over  the  heart  may  do  good.  The  eyes  should 
be  protected  and,  if  irritated,  should  receive  proper  treatment. 
In  a  few  cases  improvement  has  followed  the  treatment  of 
swellings  in  the  nose  and  operations  upon  organs  in  the  pelvis. 
These  later  procedures  should  be  undertaken  only  with  great 
caution  and  after  serious  consideration,  as  they  have  proved 
beneficial  in  only  a  very  small  number  of  cases,  and  operation 
may  aggravate  the  condition. 

Surgical  treatment,  in  which  part  of  the  gland  is  removed,  or 
in  which  the  thyroid  arteries  are  ligated,  is  to  be  recommended 
in  those  cases  that  do  not  respond  to  or  at  least  show  improve- 
ment after  six  weeks  of  proper  medical  treatment. 

Before  operating  upon  these  patients  it  is  well  to  consider 
them  carefully  as  surgical  risks:  these  patients  do  not  do 
well  if  they  are  operated  upon  late  in  the  disease,  after  a 
marked  cardiac  degeneration  and  a  state  of  cachexia  have 
developed. 

Only  partial  thyroidectomy  should  be  performed.  The 
proper  amount  of  gland  to  remove  in  each  case  must  rest  on  the 
judgment  of  the  surgeon.  Care  should  be  taken  not  to  remove 
the  parathyroid  glands  nor  to  injure  the  recurrent  laryngeal 
nerve,  etc.  Surgical  intervention  is  indicated  in  those  cases 
that  are  rapidly  progressive,  in  cases  with  grave  nervous  and 


MYXEDEMA — CRETINISM  583 

mental  symptoms,  and  in  those  in  which  there  is  evidence  of 
compression  of  the  trachea,  esophagus,  etc. 

Jonnesco's  operation  for  the  removal  of  the  cervical  sym- 
pathetic ganglia  with  their  cord  is  believed  to  exert  a  favorable 
influence  upon  the  course  of  the  disease. 

In  general  it  may  be  stated  that  in  all  cases  except  those  that 
are  of  acute  onset,  that  are  rapidly  progressive,  and  that  present 
grave  nervous  and  mental  symptoms,  an  effort  should  be  made, 
either  by  adopting  a  complete  or  a  modified  form  of  the  Weir 
Mitchell  treatment,  together  with  electricity,  diet,  hydrotherapy, 
etc.,  favorably  to  influence  the  disease.  This  attempt  should 
be  made  if  no  unfavorable  symptoms  occur  for  six  or  eight 
weeks.  If  improvement  is  continuous,  the  treatment  should  be 
persisted  in;  if,  on  the  other  hand,  there  is  little  or  no  improve- 
ment, or  if  there  is  an  increase  in  the  symptoms,  surgical  meas- 
ures should  be  promptly  resorted  to. 

Those  cases  that  are  too  ill  to  undergo  surgical  treatment, 
and  those  in  which  there  is  a  marked  persistence  of  symptoms 
even  after  proper  operative  measures  have  been  instituted,  may 
derive  benefit  from  prolonged  exposure  of  the  thyroid  gland 
and  the  thymus  glands  to  the  :r-rays. 

MYXEDEMA— CRETINISM 

This  condition  is  characterized  by  a  peculiar  swelling  of  the 
skin  and  subcutaneous  tissues,  secretory  and  trophic  disturb- 
ances, mental  changes,  etc. 

Etiology. — The  disease  may  appear  in  earliest  years  of  life,  be 
of  congenital  origin,  or  it  may  occur  later.  It  affects  females 
more  frequently  than  males.  Alcoholism,  tuberculosis,  syphilis, 
diabetes,  pregnancy,  lactation,  the  menopause,  altitude,  and 
certain  living  conditions  seem  to  predispose  to  this  condition. 
The  disease  occurs  with  frequency  in  certain  localities  of  Switzer- 
land, Austria,  Italy,  and  France.  The  direct  causes  are  disease 
that  lead  to  an  inflammatory  condition  of  the  thyroid  gland, 
with  subsequent  sclerosis  and  atrophy;  injury  to  the  gland, 
with  subsequent  degenerative  changes  and  insufficient  nutrition ; 
tumors  of  the  gland;  enlargements  of  the  gland  in  w^hich  there 


584  MANUAL   OF   NERVOUS   DISEASES 

is  a  proliferation  of  the  interstitial  tissue,  with  defective  func- 
tion; operations  upon  the  thyroid  gland  in  which  the  entire 
gland  or  too  large  a  part  of  the  gland  has  been  removed,  or  in 
cases  in  which,  after  operation  on  the  gland,  degenerative 
changes  occur.  There  may  be  a  congenital  absence  or  abnormal 
smallness  of  the  gland  from  some  unknown  cause,  etc. 

Pathology. — Examination  of  the  skin  shows  the  swelling  to 
be  due  to  a  mucous  or  mucoid  infiltration.  On  examination  of 
the  thyroid  gland  this  organ  is  seen  to  be  usually  diminished  in 
size  or  atrophied.  Experimental  and  clinical  cases  show  that 
symptoms  of  myxedema  or  cretinism  are  due  to  a  deficiency, 
a  loss  of,  or  congenital  absence  of  the  secretions  of  the  thyroid 
gland.  The  severity  of  the  symptoms  depends  upon  the  extent 
of  the  deficiency  of  the  thyroid  secretions.  The  younger  the 
affected  individual,  as  a  rule,  the  more  harmful  will  be  the  loss 
of  this  secretion. 

Symptoms. — The  onset  is  usually  gradual.  The  symptoms 
differ  somewhat  according  to  whether  the  disease  occurs  in 
early  infancy  or  somewhat  later  in  life.  Deficient  or  absent 
secretion  of  the  thyroid  gland  occasions  more  severe  symptoms 
in  young  individuals  than  in  those  that  are  older.  As  the 
result  of  a  congenital  absence  or  marked  deficiency  of  the  thyroid 
secretion  a  condition  known  as  cretinism  develops.  Physically 
the  stature  is  dwarfed;  the  fontanels  are  large  and  open;  the 
nose  is  small  and  broad;  the  lips  are  pendulous;  the  mouth  is 
open  and  the  tongue  is  thick  and  large,  being  usually  too  large 
for  the  mouth  and  hence  protruding ;  dentition  is  delayed ; 
walking  and  talking  are  acquired  late,  if  at  all;  the  skin  is  thick 
and  dry  and  of  a  yellowish  tint;  there  is  a  defective  growth  of 
the  hair,  which  is  coarse  and  thick;  the  mucous  membranes  are 
pale  and  usually  swollen;  the  facial  expression  is  stupid;  the 
eyes  are  half  closed  and  the  eyelids  are  swollen;  the  neck  is 
generally  short  and  thick ;  the  abdomen  protruding  with  a  low 
position  of  umbillicus;  the  appetite  is  increased;  obstinate 
constipation;  in  subclavicular  regions  and  in  the  axilla  fat- 
like masses  are  often  deposited.  x-Ray  examination  shows 
a  defective  and  delayed  ossification  and  persistence,  to  an 
advanced  age,  of  the  epiphyseal  cartilage;  the  genital  organs 


MYXEDEMA— CRETINISM  585 

remain  infantile,  and  signs  of  puberty  either  do  not  develop 
or  are  materially  delayed.  Intellectually  the  condition  of  these 
individuals  varies  from  a  state  of  marked  idiocy  to  one  in  which 
the  lack  of  mental  development  is  not  so  marked. 

Cases  also  occur  in  which  the  symptoms  are  not  so  prominent. 
In  these  patients  the  skin  is  dry;  the  hair  is  sparse;  the  tongue 
may  be  large;  the  stature  is  small;  the  genitalia  are  poorly 
developed;  there  is  delay  or  absence  of  the  signs  of  puberty; 
secondary  sexual  characteristics  are  absent  or  poorly  developed ; 
the  mental  development  is  deficient,  the  mentality  never  exceed- 
ing that  of  a  normal  child. 

In  the  acquired  form  of  myxedema  which  develops  after  a 
pathologic  condition  that  brings  about  a  more  or  less  deficient 
secretion  of  the  thyroid  gland,  symptoms  of  the  disease  gradually 
develop.  The  individual  complains  of  fatigue  and  weakness  in 
the  limbs,  a  feeling  of  cold,  and  more  or  less  diffuse  pain.  Next 
a  puffiness  of  the  face,  hands,  and  feet  develops.  The  swelling 
about  the  chin  and  the  eyelids  is  due  to  infiltration  of  the  skin 
and  subcutaneous  tissue.  The  face  assumes  a  heavy  expression. 
The  infiltration  of  the  skin  appears  on  the  neck  and  on  the  ex- 
tremities; the  skin  is  pale  or  yellowish,  feels  cold,  is  firm  and 
elastic,  and  does  not  pit  on  pressure.  The  secretion  of  sweat 
decreases  or  ceases,  the  skin  becomes  dry  and  rough,  the  hair 
falls  out,  and  fat-like  tumor  masses  may  appear  in  the  neck, 
axillary  spaces,  etc.  The  mucous  membranes  become  thickened 
and  infiltrated.  There  is  often  a  loss  of  the  teeth.  The  temper- 
ature of  the  body  is  usually  subnormal;  headache,  forget  fulness, 
vertigo,  weakness,  and  awkwardness  are  also  present.  The 
voice  is  usually  rough,  hoarse,  and  monotonous.  To  all  these 
evidences  there  are  added  mental  changes.  These  consist 
most  commonly  of  marked  deficiency  in  the  intellect;  the  memory 
is  impaired;  thought  processes  are  slow;  irritability  or  indifference 
is  present,  and  there  is  a  marked  tendency  to  somnambulism. 
In  some  cases  sensory  illusions  are  present,  and  even  marked 
psychoses  may  occur  in  this  condition. 

The  characteristic  features  of  myxedema  are  the  swelling, 
infiltration,  dryness  of  the  skin,  falling  out  of  the  nails,  thicken- 
ing and  infiltration  of  the  mucous  membrane,  hoarse,  rough, 


586  MANUAL   OF   NERVOUS   DISEASES 

monotonous  voice,  and  the  mental  changes  that  are  usually 
characterized  by  simple  dementia;  a  subnormal  temperature, 
an  absence,  partial  absence,  or  smallness  of  the  thyroid,  or  an 
increased  size  of  the  thyroid  gland.  The  examination  reveals 
the  fact  that  there  is  present  either  a  tumor  or  an  increased 
size  of  the  gland,  due  to  a  proliferation  of  interstitial  tissue. 
Albuminuria  and  glycosuria  occasionally  occur. 

Course. — This  disease  usually  develops  slowly  and  runs  a 
progressive  course.  In  cretinism  the  first  evidences  are  apparent 
after  weaning  or  within  the  first  two  years  of  life.  Unless 
treated,  the  symptoms  become  frankly  evident  within  the  first 
few  years.  In  young  individuals  or  adults  the  symptoms  may 
begin  shortly  after  an  operation  on  the  thyroid  or  following  an 
infectious  disease,  injury,  exposure,  labor,  etc.;  or  they  may  not 
manifest  themselves  for  several  months  after  these  exciting 
causes  have  taken  place.  General  physical  weakness,  intellectual 
torpidity,  changes  in  the  skin,  and  subnormal  temperature 
develop.  The  face  loses  expression,  and  usually  the  entire 
body  becomes  larger,  due  to  the  deposit  of  fat.  Remissions  may 
occur. 

Prognosis. — In  cretinism  there  is,  as  a  rule,  no  tendency  to 
spontaneous  improvement.  Many  of  these  cases  die  in  child- 
hood. Under  proper  treatment,  however,  marked  improve- 
ment takes  place.  The  intellectual  progress  is  much  slower 
than  are  the  physical  changes.  The  earlier  the  treatment  is 
begun,  the  more  hopeful  is  the  outlook. 

In  cases  occurring  in  young  adults  the  prognosis  is  grave, 
death  being  generally  due  to  some  intercurrent  disease,  of  which 
pulmonary  tuberculosis  is  the  most  frequent.  Unless  properly 
treated,  death  occurs  either  from  an  intercurrent  disease  or  from 
pronounced  cachexia. 

The  prognosis  depends  upon  the  integrity  of  the  parathyroid 
glandules,  upon  the  amount  of  the  thyroid  gland  removed,  and 
upon  the  age  of  the  individual.  If  symptoms  of  tetany  develop 
along  with  the  symptoms  of  myxedema,  the  outlook  is  very 
grave.  In  those  cases  in  which  too  much  of  the  gland  has  been 
removed,  or  in  which,  after  operation,  sclerotic  changes  take 
place  in  the  gland,  in  young  adults  the  outlook  is  not  favor- 


MYXEDEMA — CRETINISM  ^  587 

able;  in  older  individuals,  with  proper  treatment,  it  is  more 
hopeful. 

Diagnosis. — ^The  condition  is  diagnosd  without  difficulty. 
The  combination  of  the  characteristic  symptoms,  the  changes 
in  the  skin,  the  facial  expression,  the  increased  weight,  the  general 
weakness,  the  mental  feebleness,  etc.,  make  the  condition  one 
easily  recognized.  It  is  always  important  to  differentiate  the 
infiltration  of  the  skin  from  an  edematous  state  of  the  skin,  as 
the  latter  may  occur  in  cardiac  and  renal  diseases,  which  may 
also  be  accompanied  by  mental  changes.  A  careful  examina-' 
tion,  together  with  the  history  of  the  case,  will  usually  enable 
one  to  differentiate  a  true  cardiac  or  renal  disease  from  myx- 
edema. 

Sporadic  and  endemic  cretinism  must  be  differentiated  from 
mongolian  idiocy,  achondroplasia,  congenital  adiposity,  and  a 
combination  of  idiocy  with  infantile  dwarfism. 

As  a  rule,  the  typical  skin  changes  are  absent  in  these  diseases. 
The  x-ray  examination  of  the  bones  shows  the  lack  of  ossification, 
with  persistence  of  the  epiphyseal  cartilage  in  cretinism  and 
the  absence  of  these  findings  in  the  other  conditions.  The 
typical  facial  expression  in  cretinism,  the  thick  lips,  the  protrud- 
ing tongue,  the  short  neck,  etc.,  are  in  marked  contrast  to  the 
characteristic  appearance  in  these  other  diseases. 

Treatment  of  Cretinism. — In  the  endemic  form  the  prophy- 
lactic treatment  is  important.  In  localities  w^ere  this  disease 
exists  improvement  of  hygienic  surroundings  and  pure  drinking- 
water  are  important.  Owing  to  the  fact  that  heredity  certainly 
plays  some  part  in  the  transmission  of  this  disease,  it  is  advisable 
that  those  families  in  which  the  disease  occurs  should  intermarry 
only  with  families  that  are  free  from  the  taint.  Upon  the  ap- 
pearance of  the  first  symptoms  the  patients  should  be  sent  away 
from  the  locality  in  which  the  disease  exists  into  one  where  it 
does  not  occur.  Treatment  should  be  undertaken  as  early  as 
possible — the  extent  of  the  improvement  is  dependent  chiefly 
upon  the  age  at  which  treatment  is  instituted.  Improvement 
is  possible  even  when  grow^th  has  ceased. 

The  patient  should  be  placed  amid  as  favorable  hygienic 
surroundings  as  possible,  and  since  these  patients  usually  suffer 


588  MANUAL   OF   NERVOUS   DISEASES 

from  cold,  they  generally  do  better  in  a  moderately  warm 
climate.  The  diet  should  be  regulated  and  constipation  rec- 
tified. 

Thyroid  extract,  given  in  the  form  either  of  freshly  prepared 
liquor  thyroidei  or  of  dried  thyroid  glands,  is  the  chief  remedy  to 
be  employed.  The  thyroid  extract  should  be  given  at  first  in 
small  doses,  beginning  with  one  grain  of  the  dried  gland  or 
five  minims  of  the  liquor,  given  at  first  once  a  day,  and  then 
two  or  three  times  a  day,  and  then  increasing  the  dose  until  the 
effects  begin  to  appear.  Usually  within  a  few  days  after  the 
administration  of  the  proper  doses  the  skin  assumes  a  more 
natural  condition,  there  is  a  return  of  the  secretion,  cyanosis 
disappears,  and  there  is  a  gradual  loss  of  weight.  Later  there 
is  rapid  growth  of  the  extremities;  the  tongue  becomes  smaller, 
the  muscles  grow  stronger,  the  amount  of  urine  increases,  the 
individual  manifests  more  interest  in  his  surroundings,  and  there 
is  a  gradual  disappearance  of  the  apparent  dementia.  The 
improvement  is  most  marked  in  younger  patients;  in  older 
patients  the  treatment  has  little  effect  upon  the  mental  condition. 
If  the  dose  of  thyroid  extract  is  too  large,  dangerous  symptoms 
may  occur,  of  which  the  most  comm^on  are  tachycardia,  diarrheal 
attacks,  convulsions,  general  weakness,  etc.;  consequently  great 
care  should  be  taken  in  the  administration  of  this  drug,  and 
upon  the  first  appearance  of  symptoms  pointing  to  overdosage 
its  administration  should  be  discontinued  for  several  days, 
and  the  treatment  then  resumed  with  smaller  doses. 

The  Treatment  of  Myxedema. — ^The  treatment  of  this  dis- 
ease is  very  simple  and  certain,  and  the  effect  is  most  marked. 
The  extract  of  the  thyroid  gland  of  sheep,  in  proper  doses  and 
gradually  increased,  should  be  given,  care  being  taken  to  avoid 
inactive  or  decomposed  preparations. 

Small  doses  are  given  at  first  and  gradually  increased.  Three 
or  four  days  after  administration  the  effect  of  the  thyroid 
extract  manifests  itself.  The  body  weight  diminishes,  the 
peculiar  thickening  of  the  skin  disappears  and  it  becomes  more 
moist,  the  pulse  is  somewhat  more  rapid,  the  temperature 
becomes  normal,  and  there  is  a  marked  improvement  in  the 
mental  symptoms.     It  is  well  to  begin  with  two  grains  two  or 


TETANY  589 

three  times  a  day,  gradually  increasing  to  three,  four,  or  five 
grains  given  three,  four,  or  five  times  a  day.  Upon  the  appear- 
ance of  symptoms  of  hyperthyroidism  the  thyroid  extract  should 
be  discontinued  and  its  use  not  resumed  for  several  days,  and 
then  the  treatment  taken  up  again,  beginning  with  small  doses. 
The  diet  should  be  varied,  but  should  consist  chiefly  of 
vegetables.  Tonics  may  be  given.  The  general  hygienic  con- 
ditions .of  the  patient  should  be  properly  supervised.  In  both 
cretinism  and  myxedema  it  is  necessary  to  continue  the  admin- 
istration of  thyroid  gland  indefinitely;  generally  it  is  wise  at 
intervals  to  discontinue  the  administration  of  the  gland  for 
a  short  time  and  then  to  return  to  it  again. 

TETANY 

This  disease  is  characterized  by  bilateral  intermittent  tonic 
spasms,  which  are  usually  painful.  They  affect  principally 
the  hands,  and  sometimes  both  the  upper  and  the  lower  extrem- 
ities. They  are,  as  a  rule,  unaccompanied  by  any  disturbance 
of  consciousness. 

Etiology. — This  disease  occurs  more  frequently  in  children 
than  in  adults,  and  very  rarely  in  old  age.  It  affects  males  more 
frequently  than  females.  Certain  occupations  seem  to  predis- 
pose to  this  condition;  thus  shoemakers  and  tailors  are  prone 
to  be  affected,  probably  owing  to  a  poison  taken  into  the  system 
from  some  article  used  in  these  trades.  It  sometimes  occurs  in 
women  during  pregnancy,  lactation,  or  the  puerperal  state.  It 
occurs  more  frequently  during  the  early  spring  months  in 
children  who  have  been  living  amid  bad  hygienic  conditions, 
who  are  suffering  from  rickets,  gastro-intestinal disease,  intestinal 
parasites,  chronic  pulmonary  disease,  and  in  those  who  are 
poorly  nourished.  It  may  also  occur  after  typhoid  fever  or 
following  any  of  the  infectious  diseases,  after  removal  of  the 
thyroid  gland  with  injury  to  the  parathyroids,  dilatation  of  the 
stomach,  after  chronic  intoxication  from,  alcohol,  lead,  chloro- 
form, or  in  nephritis,  etc. 

Pathology. — ^At  the  present  time  tetany  is  almost  universally 
attributed  to  an  absence  or  an  insufl&ciency  of  the  secretions  of 


590  MANUAL   OF   NERVOUS   DISEASES 

the  parathyroid  glands.  It  is  believed  that  the  role  played  by 
toxemias,  whether  of  internal  or  of  external  origin,  by  reflex 
irritation,  etc.,  becomes  an  active  one  in  the  presence  of  an 
insufficient  secretion  of  the  parathyroid  glands.  No  constant 
pathologic  changes  are  found;  in  some  cases  hyperemia  and 
circumscribed  hemorrhages,  cloudy  swelling  of  the  ganglion-cells, 
etc.,  were  found  in  the  spinal  cord;  these  were  absent  in  others. 
In  still  other  cases  changes  were  found  in  the  cortex  of  the  brain 
and  in  the  thyroid  glands. 

Symptoms. — ^As  a  general  rule,  before  the  occurrence  of 
muscular  spasms  there  are  pains  in  the  limbs,  sometimes  head- 
ache, a  general  feeling  of  illness,  and  very  often  paresthesias. 
Either  with  or  without  these  symptoms  a  cramp-like  spasm 
occurs  in  which,  generally,  the  muscles  of  the  hands  and  fingers 
are  chiefly,  and  sometimes  solely,  affected.  The  attitude  of  the 
fingers  and  the  hands  in  these  cases  is  characteristic :  the  middle 
and  terminal  phalanges  are  extended,  and  the  basal  phalanges 
are  strongly  flexed,  the  fingers  being  pressed  together,  and  the 
thumb  turned  in  and  covered  with  the  other  fingers. 

In  the  more  marked  cases  the  hand  is  flexed  at  the  wrist  and 
the  forearm  upon  the  arm;  the  arm  is  usually  held  close  to  the 
thorax.  When  the  fingers  are  pressed  closely  together  over  the 
thumb  the  hands  assume  a  cone  shape  which  resembles  the 
writer's  or  accoucheur's  position.  Sometimes  the  fingers, 
instead  of  being  flexed,  are  spread  out,  and  at  times  the  hand 
assumes  a  claw-like  position.  The  lower  extremities  are  also 
often  involved,  and  when  they  are,  the  flexors  of  the  toes  be- 
come tonically  contracted,  the  toes  being  strongly  flexed,  the 
arch  of  the  foot  accentuated,  and  the  foot  extended  at  the 
ankle-joint,  giving  rise  to  the  equinovarus  position.  All  the 
muscles  of  the  leg  may  be  affected;  in  this  case  the  legs  are  stiff 
and  may  be  either  abducted  or  adducted.  The  muscles  of  the 
trunk,  tongue,  pharynx,  and  larynx  may  be  involved,  and  deg- 
lutition, respiration,  etc.,  may  be  affected;  this  occurs,  how- 
ever, only  in  very  severe  cases. 

These  spasms  usually  come  on  suddenly  and  subside  gradually, 
but  recur  in  a  series  of  attacks.  The  spasm  is  generally  attended 
by  pain  in  the  affected  muscles.     In  most  cases  the  spasms  are 


TETANY  591 

limited  to  the  muscles  of  the  fingers  and  hands;  in  other  cases 
they  are  very  much  more  extensive;  they  also  vary  in  intensity, 
in  some  cases  lasting  only  a  few  minutes,  being  very  mild  and 
easily  overcome,  whereas  in  other  cases  they  are  much  more 
severe  and  may  last  from  a  few  minutes  to  several  hours  or 
even  days. 

After  the  spasm  has  subsided  the  paresthesia  and  sense  of 
muscle  tension  may  remain  for  some  time.  In  some  cases  after 
the  attack  has  passed  off  muscle  weakness  remains.  During 
the  attack  the  mind  is  not  affected,  but  in  cases  in  which  a 
marked  toxemia  is  present  there  may  also  be  mental  confusion. 
In  children  it  is  not  uncommon  for  tetany  to  be  associated  with 
convulsive  seizures.  The  attack  is  often  attended  by  a  slight 
rise  of  temperature — 100°  to  102°  F. — and  an  increase  in  the 
pulse-rate. 

The  spasms  may  be  separated  by  intervals  of  varying  duration, 
but,  as  a  rule,  they  follow  each  other  in  quick  succession,  and  in 
some  cases  the  muscles  are  never  completely  relaxed. 

In  addition  to  the  spasms,  which  are  the  most  important 
symptoms  of  the  disease,  a  number  of  characteristic  signs 
occur : 

Trousseau' s  Sign. — ^Trousseau  found  that  pressure  on  a  ner^^e 
or  a  nerve  plexus  in  the  interval  between  spasms  will  bring  on  a 
spasm  of  the  muscles  supplied  by  the  compressed  nen.'-e.  The 
spasm  may  not  follow  for  from  a  half  minute  to  several  minutes 
after  the  pressure  is  exerted.  Trousseau's  sign  is  not  found  in 
any  other  disease,  and  is  pathognomonic  of  tetany. 

Chvostek^s  Sign. — This  sign  depends  upon  an  increased 
mechanical  excitability  of  the  motor  nerves.  Slight  percus- 
sion upon  a  motor  or  mixed  nerve  may  produce  contraction  in 
the  muscles  which  they  innerv^ate;  this  is  most  readily  brought 
out  by  slight  percussion  over  the  seventh  nerv^e,  when  there 
occurs  the  so-called  face  phenomenon,  which  manifests  itself 
by  marked  twitchings  or  spasmodic  contractions  of  the  face. 
This  sign  is  not  constant,  and  occurs  in  diseases  other  than 
tetany. 

Hofman'^s  Sign. — This  sign  depends  upon  an  increased 
mechanical  and  electric  excitability  of  the  sensory  nerves.     In 


592  MANUAL   OF   NERVOUS   DISEASES 

an  affected  individual  slight  pressure  on  a  sensory  nerve  produces 
paresthesias  in  the  region  supplied  by  the  nerve,  whereas 
similar  pressure  in  a  normal  individual  would  produce  only  a 
local  sensation.  The  sensation  caused  by  pressure  on  these 
nerves  in  an  individual  with  tetany  is  similar  to  that  which 
occurs  in  a  normal  individual  who  srikes  the  ulnar  nerve, 
causing  numbness,  paresthesia,  etc. 

Stimulation  of  the  sensory  nerves  by  the  galvanic  current,  if 
of  sufficient  strength,  produces  sensation  in  the  nerve  and  radiates 
into  the  surrounding  structures:  in  tetany  these  sensations  and 
the  radiating  sensation  occur  with  very  much  weaker  currents. 
This  symptom  is  also  present  at  times  in  neuropathic  indi- 
viduals. 

ErVs  Sign. — Increased  electric  excitability  of  the  motor 
nerves.  This  sign  is  present  in  almost  every  case.  Mild 
galvanic  stimulation  of  a  motor  nerve  gives  rise  to  prompt  and 
marked  muscle  contraction;  this  contraction  is  usually  pro- 
longed. Slightly  stronger  currents  give  rise  to  a  tetanic  con- 
traction which  may  not  subside  until  the  current  is  interrupted. 
Increased  excitability  to  the  galvanic  is  more  commonly  present 
than  to  the  faradic  current.  The  ulnar  nerve  is  the  nerve  which 
most  frequently  gives  a  positive  response  to  this  sign,  although 
other  nerves  will  also  respond  positively. 

Among  the  unusual  symptoms  that  occur  in  this  disease  are 
hyperidrosis,  especially  after  attacks;  albuminuria,  glycosuria, 
redness  and  edema  of  the  skin,  urticaria,  herpes,  falling  out  of 
the  nails,  loss  of  the  hair,  and  in  some  few  cases  paralysis, 
especially  of  the  muscles  of  the  sacral,  lumbar,  and  pelvic 
regions. 

The  reflexes  are  usually  normal,  but  may  be  increased  or 
decreased.  No  objective  sensory  disturbances  are  present. 
In  tetany  following  removal  of  the  thyroid  glands,  epileptic 
conditions  sometimes  occur.  Occasionally  tetany  may  be 
combined  with  myxedema,  exophthalmic  goiter,  etc. 

Course. — ^The  entire  disease  may  be  marked  by  but  a  few 
attacks,  or  may  last  for  several  weeks  or  months.  Usually 
before  the  attacks  come  on  there  is  a  peculiar  sensitiveness  of  the 
nerves  and  paresthesias  occur;  these  are  followed  by  the  spas- 


TETANY  593 

modic  attacks,  that  may  last  for  from  a  few  moments  to  several 
days.  The  attacks  may  occur  every  day  or  several  times  a  day, 
or  may  be  more  or  less  continuous,  or  they  may  recur  only  after 
more  or  less  prolonged  intervals.  The  individual  spasms  may 
last  for  from  a  few  minutes  to  several  hours.  The  disease  may 
run  its  course  in  a  few  days,  during  which  one  or  more  attacks 
may  occur,  or  it  may  persist  for  weeks  or  months.  Chronic 
forms  occur  in  which  remissions  are  present  and  which  may  last 
for  many  years. 

Prognosis. — In  the  majority  of  cases  the  prognosis  is  good. 
In  those  cases  in  which  tetany  occurs  after  removal  of  the  thy- 
roid gland,  or  when  it  occurs  in  persons  suffering  from  gastric 
dilatation,  the  outlook  is  not  so  favorable,  although  even  under 
these  conditions  recovery  is  possible.  WTien  tetany  occurs  in 
children  who  are  suffering  from  gastro-intestinal  diseases,  death 
frequently  takes  place  from  the  primary  disease.  When  the 
respiratory  muscles  are  affected,  tetany  may  prove  fatal, 
particularly  if  the  diaphragm  is  involved.  Frankl-Hochwart 
states  that  tetany  occurring  in  pregnant  women  presents  a  grave 
prognosis. 

Diagnosis. — This  condition  is  usually  recognized  without 
difficulty,  as  the  spasms  are  characteristic.  At  times  the  condi- 
tion must  be  differentiated  from  tetanus:  in  the  latter  disease 
the  spasms  usually  affect  first  the  muscles  of  the  jaw  and  neck, 
are  generally  intermittent,  and,  as  a  rule,  there  is  an  elevation  of 
temperature.  From  hysteria  tetany  is  differentiated  by  the 
absence  of  the  Trousseau  and  Erb  signs,  and  by  the  fact  that  in 
hysteria  the  spasmodic  seizure  is  often  unilateral. 

Treatment. — It  is  important  to  make  a  careful  examination 
to  discover  the  possible  cause  of  the  condition.  Free  move- 
ment of  the  bowels  is  to  be  brought  about  by  the  administration 
of  castor  oil,  calomel,  and  rarely  by  salines.  The  nutrition  of 
the  patient  should  be  carefully  looked  after,  and  the  diet  regu- 
lated. Water  should  be  taken  freely,  and  if  there  is  evidence 
of  gastro-intestinal  putrefaction,  this  should  be  corrected  by 
castor  oil,  modification  of  the  diet,  and  gastro-intestinal  an- 
tiseptics, such  as  zinc  sulphocarbolate,  salol,  resorcin,  etc. 
In  those  cases  occurring  during  pregnancy  it  may  be  necessary' 
38 


594  MANUAL   OF   NERVOUS   DISEASES 

to  interrupt  the  gestation.  In  those  occurring  during  lactation 
it  is  advisable  to  wean  the  child.  If  the  condition  occurs  after 
operations  upon  the  thyroid  gland,  the  administration  of 
thyroid  and  parathyroid  extract  is  indicated.  Many  cases  do 
well  on  calcium  lactate,  the  doses  of  which  is  to  be  regulated 
according  to  the  age  of  the  patient. 

In  all  cases  it  is  important  carefully  to  treat  the  patient's 
general  condition,  and  to  make  every  effort  to  remove  or  to 
relieve  the  underlying  cause. 

MYASTHENIA   GRAVIS 

Etiology. — Females  are  more  frequently  affected  than  males. 
The  disease  usually  appears  between  the  twentieth  and  the 
thirtieth  year,  but  may  occur  earlier  or  later.  Overexertion, 
emotional  excitement,  the  infections,  especially  grip,  along  with 
Graves'  disease,  pregnancy,  etc.,  are  among  the  common  coexist- 
ing or  exciting  causes  of  the  disease.  In  many  cases  an  increased 
size  of  the  thymus  gland  has  been  noticed,  and  in  some  cases 
tumors  of  this  gland  have  been  found.  The  condition  is  be- 
lieved to  be  due  to  some  error  of  secretion  of  the  ductless  glands, 
or  to  a  toxic  agent  of  unknown  origin  that  has  a  selective  action 
upon  the  muscles.  Examination  of  the  muscles  reveals  numer- 
ous collections  of  lympathic  cells  more  or  less  constantly  pres- 
ent along  the  course  of  the  lymphatics  and  about  the  blood- 
vessels. 

Symptoms. — ^The  disease  is  characterized  by  abnormal  fatigue 
of  the  muscles  after  exertion.  It  usually  manifests  itself  in  pto- 
sis or  a  form  of  strabismus,  producing  double  vision,  followed 
by  weakness  of  the  muscles  of  the  face,  tongue,  pharynx,  larynx, 
etc.  This  weakness  evidences  itself  in  difficulty  of  speech  and 
in  chewing,  in  swallowing,  and  in  using  the  lips.  The  weakness 
usually  extends  downward  to  the  arms,  hands,  and  legs.  This 
weakness  is  at  first  characterized  by  the  fact  that  after  rest  it 
disappears,  and  the  patient  is  apparently  normal,  only  to  recur 
on  using  the  part;  so  that  at  first  the  patient  may  be  able  to 
talk  plainly,  chew  well,  or  see  clearly;  after  using  the  eyes 
ptosis  and  strabismus  develop,  and  he  sees  double;  after  chewing 


MYASTHENIA    GRAVIS  595 

for  a  short  time  he  tires  and  uses  his  hands  to  aid  his  jaws  in 
their  movements.  Later  on  the  disease  becomes  so  marked 
that  a  few  movements  completely  exhaust  the  patient.  As 
the  disease  progresses  a  paralysis  of  the  muscles  of  the  eyeballs, 
face,  and  mouth  develops,  lending  to  the  face  a  mask-like  ap- 
pearance that  closely  resembles  that  seen  in  bulbar  palsy. 
There  is  usually  some  dribbling  of  saliva  from  the  mouth,  the 
speech  becomes  low  and  very  indistinct,  and  shortness  of  breath 
develops.  Failure  of  respiration  and  a  terminal  pneumonia 
are  generally  the  cause  of  death.  Increased  pulse-rate  and 
occasional  rise  of  temperature  frequently  occur.  No  sensor}^ 
disturbances  are  present.  The  affected  muscles  do  not  show 
fibrillary  tremors  nor  undergo  atrophy.  Muscle  tone  is  usually 
about  normal;  the  tendon  and  skin  reflexes  are  normal  or  in- 
creased. Examination  of  the  muscles  with  the  electric  current 
at  first  shows  nothing  abnormal,  but  if  exercised  continuously 
by  either  the  galvanic  or  the  faradic  current,  they  show  a  pro- 
gressively decreasing  contractility,  finally  failing  to  react  to 
either  current.  This  is  called  the  mvasthenic  reaction,  and  it 
is  characteristic  of  the  disease. 

Along  with  the  disease  there  is,  as  a  rule,  some  depression, 
or  the  patient  may  be  very  emotional  and  hysteric.  Although 
the  disease  usually  first  attacks  the  muscles  of  the  face  or  of  the 
upper  extremities,  it  may  begin  in  the  legs  and  extend  upward. 
The  distribution  of  the  symptoms  is  generally  bilateral,  although 
commonly  one  side  is  affected  more  than  the  other.  The  onset 
of  the  disease  is  somewhat  variable:  in  some  cases  the  condition 
develops  within  a  few  days  or  weeks,  and  in  others  its  progress 
is  much  slower. 

Course  and  Prognosis. — This  disease  runs  an  irregular  course. 
In  some  cases  a  fatal  termination  occurs  within  a  very  short 
time;  in  others  it  takes  place  within  one  or  two  years;  in  still 
others  there  are  marked  remissions  and  intermissions,  the  dis- 
ease being  influenced  by  treatment,  and  death  not  taking  place 
for  many  years.  In  a  few  cases  recovery  apparently  takes 
place.  The  prognosis  seems  to  be  better  in  those  cases  that 
begin  in  the  extremities. 

Diagnosis. — ^The  diagnosis  is  made  from  rapid  fatigue  of  the 


596  MANUAL   OF   NERVOUS   DISEASES 

muscles  on  exertion;  from  the  appearance  of  the  myasthenic 
reaction;  from  the  development  of  double  vision,  ptosis,  diffi- 
culty in  speech  and  in  swallowing,  rapid  fatigation  of  the  facial 
muscles  and  of  the  muscles  of  the  limbs,  head,  and  neck,  and  espe- 
cially of  the  muscles  of  the  jaw.  The  absence  of  atrophy  and  of 
fibrillary  tremors,  as  well  as  of  sensory  disturbances,  is  also 
a  guide  to  the  diagnosis.  The  condition  is  to  be  differentiated 
from  hysteria  and  bulbar  paralysis.  From  hysteria  it  is  differ- 
entiated by  the  fact  that  strabismus  is  never  present  unless  as 
a  congenital  defect,  and  then  it  does  not  disappear  after  rest. 
The  difficulty  in  swallowing  in  hysterics  is  caused  by  spasms  of 
the  muscles  of  the  throat,  and  food  is  actively  rejected  through 
the  mouth,  whereas  in  myasthenia  the  paralysis  of  the  throat 
leads  to  regurgitation  of  food  through  the  nose;  if  food  is  swal- 
lowed, it  may  enter  the  larynx,  giving  rise  to  serious  respiratory 
disturbances.  In  hysteria  the  patient  speaks  in  a  low  tone  or 
in  a  whisper,  the  articulation  being  good,  whereas  in  myasthenia 
the  speech  is  slurring,  indistinct,  and  due  to  weakness  of  the 
muscles  of  the  tongue,  larynx,  and  face.  Dyspnea,  if  present 
in  hysteria,  is  not  attended  by  cyanosis  or  physical  signs  of 
pulmonary  congestion;  in  myasthenia  there  are  usually  cyanosis 
and  accumulation  of  fluid  in  the  throat  and  lungs.  The  myas- 
thenic reaction  is  never  present  in  hysteria,  but  is  rarely  absent 
in  myasthenia. 

From  bulbar  paralysis  this  condition  is  differentiated  by  the 
fact  that  in  bulbar  paralysis  the  eye  muscles  are  usually  the 
last  to  be  involved,  whereas  in  myasthenia  they  are  among  the 
first.  In  bulbar  paralysis  atrophy  always  occurs  after  the 
disease  has  existed  for  a  short  time,  but  practically  never  occurs 
in  myasthenia.  In  bulbar  paralysis  we  have  the  reaction  of 
degeneration:  in  myasthenia,  the  myasthenic  reaction;  in  bulbar 
paralysis  there  are  usually  fibrillary  tremors,  which  are  absent 
in  myasthenia;  in 'myasthenia  we  have  an  early  involvement  of 
the  extremities,  whereas  in  bulbar  palsy  this  occurs  only  when 
the  bulbar  symptoms  are  the  early  manifestations  of  an  amyo- 
trophic lateral  sclerosis,  and  in  this  condition  there  are  the 
spastic  lower  extremities,  with  a  marked  increase  in  the  tendon- 
reflexes.    In  bulbar  palsy  the  symptoms  are  not  improved  by 


DISORDERS    OF    THE    PITUITARY    BODY  597 

rest,  whereas  the  contrary  is  the  case  early  in  myasthenia.  The 
symptoms  of  bulbar  palsy  usually  come  on  slowly;  in  myasthenia 
gravis  they  are  of  much  more  rapid  development. 

Treatment. — The  most  important  part  of  the  treatment  is 
to  shield  the  affected  muscles  from  all  fatigue.  The  patient 
should  be  placed  at  rest  in  bed  in  a  quiet  room,  and  not  be 
allowed  to  talk  or  to  use  the  eyes.  Nutrition  should  be  main- 
tained, and  the  diet  should  be  as  diversified  as  possible,  but  so 
prepared  as  to  require  the  least  possible  exertion  in  mastication 
and  swallowing.  The  bowels  should  be  kept  open.  The  pa- 
tient's mind  should  be  diverted,  and  suitable  tonics  adminis- 
tered. The  effect  of  repeated  prolonged  exposure  of  the  thy- 
mus and  thyroid  glands  to  the  x-ray  may  be  tried. 

DISORDERS   OF  THE  PITUITARY  BODY 

The  pituitary  body  or  gland  consists  of  two  portions — the 
pars  anterior,  which  is  developed  from  the  pouch  of  Rathke, 
which  originates  from  the  buccal  cavity,  and  a  pars  posterior, 
which  develops  from  the  anterior  cerebral  vesicle,  and  is  con- 
nected with  the  third  ventricle  by  the  infundibulum.  Between 
the  pars  anterior  and  surrounding  the  posterior  lobe  there  is  an 
epithelial  tissue  which  is  of  different  histologic  appearance  from 
the  lobe.  This  tissue  is  called  the  pars  intermedia.  We  there- 
fore have  the  h}"pophysis  cerebri,  consisting  of  three  structures, 
the  anterior  lobe,  and  the  pars  intermedia,  which  are  of  epithe- 
lial origin,  and  the  posterior  lobe,  which  is  of  neural  origin. 

The  posterior  lobe  is  poorly  supplied  with  blood-vessels, 
whereas  the  anterior  lobe  is  highly  vascular. 

The  anterior  lobe  is  made  up  of  cells  that  have  a  peculiar 
straining  reaction,  the  difference  being  thought  to  represent 
different  stages  of  activity  in  the  same  t}^e  of  cells.  The  active 
cells  seem  to  distribute  themselves  in  the  neighborhood  of  the 
thin  walls  of  the  venous  sinuses  into  which  the\'  doubtless  dis- 
charge their  secretions.  In  the  pars  intermedia  cells  are  found 
that  have  a  tendency  to  secrete  colloid,  resembling  in  appearance 
the  secretions  characteristic  of  the  thyroid  gland. 

Under  certain  circumstances  these  cells  seem  to  invade  the 


598  MANUAL   OF   NERVOUS   DISEASES 

posterior  lobe,  into  which  the  product  of  their  secretion  is  dis- 
charged, and  through  this  structure  toward  the  infundibular 
cavity,  to  find  its  way  finally  into  the  third  ventricle. 

The  posterior  lobe  itself  contains  no  true  nerve-cells,  being 
made  up  of  the  ependyma  and  neuroglia  tissue.  Whether  the 
posterior  lobe  actually  has  a  secretion  of  its  own,  or  whether  it 
serves  to  modify  or  merely  to  transmit  the  secretion  from  the 
pars  intermedia,  are  questions  that  still  await  solution. 

Functions  of  the  Hypophysis  Cerebri. — The  anterior  lobe 
secretes  a  substance  that  apparently  enters  the  blood  and  in- 
fluences skeletal  growth.  An  increase  of  the  secretion  of  the 
anterior  lobe,  if  it  occurs  during  infancy,  brings  about  a  condi- 
tion known  as  gigantism;  when  it  occurs  later  in  life,  a  condition 
known  as  acromegaly  results. 

The  secretion  of  the  posterior  lobe  seems  to  be  more  closely 
allied  to  the  processes  of  tissue  metabolism  and  to  the  activity 
of  the  renal  and  vascular  system.  In  diseased  conditions  of  the 
pituitary  gland  there  may  be  combinations  of  inactivity  of  the 
posterior  lobe,  with  overactivity  of  the  anterior  lobe;  of  over- 
activity of  the  posterior  lobe,  with  inactivity  of  the  anterior 
lobe;  of  overactivity  of  both  lobes,  or  of  deficient  activity  of 
both  lobes — these  combinations  giving  rise  to  a  variety  of 
symptoms.  Further  modification  of  the  symptoms  is  dependent 
upon  whether  these  various  disturbances  of  the  functions  of  the 
gland  occur  before  or  after  adolescence. 

Etiology. — Inheritance  may  have  some  effect  in  predisposing  to 
diseased  conditions  of  the  pituitary  gland.  Defects  are  respon- 
sible in  a  certain  number  of  cases,  and  infectious  diseases  and 
injury  are  also  causative  factors.  Adolescence,  puberty,  and 
pregnancy  are  the  periods  of  life  at  which  disturbance  of  this 
gland  is  more  apt  to  occur.  Abnormal  activity  or  diseased 
conditions  of  other  ductless  glands  may  bring  about  abnormal 
activity  of  the  pituitary  gland. 

Symptoms. — The  symptoms  of  disorders  of  the  pituitary 
gland  may  be  divided  into  various  groups:  First,  symptoms 
that  are  due  to  disturbance  of  the  secretions  of  the  gland  itself; 
secondly,  those  symptoms  that  are  due  to  an  abnormal  physical 
state  of  the  gland  bring  about  local  or  general  cerebral  symptoms, 


DISORDERS    OF    THE    PITUITARY    BODY  599 

and,  thirdly,  symptoms  due  to  a  disturbed  activity  of  the  other 
ductless  glands. 

Symptoms  Due  to  Disturbance  of  the  Secretion  of  the  Pituitary 
Body. — The  glandular  manifestations  occurring  before  adoles- 
cence give  rise  to  the  following  types :  There  may  occur  gigantism, 
with  abnormal  and  premature  sexual  developement;  or  gigantism 
with  an  infantile  condition  of  the  sexual  organs.  Another  type 
occurs  which  is  described  by  Frohlich,  in  which  there  is  a  stunt- 
ing of  the  growth  and  an  infantile  development  of  the  genitalia. 
Other  types  occur  in  which  adiposity  is  a  common  clinical  symp- 
tom, and  which  are  accompanied  by  delayed  or  deficient  genital 
development,  and  in  which  there  is  either  a  decrease  or  an  in- 
crease in  the  skeletal  development. 

When  these  disturbances  occur  after  adolescence,  an  increased 
secretion  of  the  anterior  lobe  gives  rise  to  acromegaly,  which  may 
or  may  not  be  accompanied  by  symptoms  of  an  increased  or 
decreased  secretion  of  the  posterior  lobe,  this  giving  rise,  in 
case  of  increased  secretion  of  the  posterior  lobe,  to  a  decreased 
carbohydrate  tolerance,  emaciation,  high  blood-pressure,  poly- 
uria, irritability,  etc.  In  cases  of  decreased  secretion  of  the  pos- 
terior lobe  there  occur  adiposity,  increased  carbohydrate  toler- 
ance, mental  heaviness,  subnormal  temperature,  and  regression 
of  the  sexual  characteristics. 

In  cases  in  which  the  disturbance  of  secretion  is  principally 
in  the  posterior  lobe,  there  occur,  when  there  is  an  increased 
secretion,  irritability,  restlessness,  increased  blood-pressure, 
and  decreased  carbohydrate  tolerance;  if  this  occurs  before 
adolescence,  a  premature  and  abnormal  sexual  development 
takes  place. 

If  there  is  a  decreased  secretion  of  the  posterior  lobe,  an 
adiposity  occurs  that  is  generalized,  involving  the  internal 
organs  as  well  as  the  subcutaneous  tissue;  the  deposit  of  fat  is 
especially  marked  in  the  anterior  abdominal  wall  and  in  the 
liver,  where  the  cells  are  replaced  by  globules  of  fat.  Increased 
carbohydrate  tolerance  takes  place,  the  temperature  is  sub- 
normal, the  pulse  is  slow,  there  is  mental  heaviness,  and  if  this 
condition  develops  before  adolescence,  there  is  a  delayed  or 
deficient   development   of   the   sexual   organs,    together   with 


6oo  MANUAL   OF   NERVOUS   DISEASES 

absence  of  the  pubic  and  axillary  hair.  If  the  decreased  secre- 
tion takes  place  after  adolescence,  there  is,  in  addition  to  the 
other  signs,  a  regression  of  the  sexual  characteristics. 

Other  cases  are  seen  that  may  be  attributed  to  disturbed 
secretion  of  this  gland,  in  which  other  combinations  of  symptoms 
occur. 

Cutaneous  and  subcutaneous  changes  occur  in  increased  and 
decreased  secretion  of  the  gland:  In  increased  secretion  there 
are  external  thickening  of  the  epidermis,  increase  in  the  size 
of  the  hair-foUicles,  and  hypertrophy  of  the  papilla,  together 
with  enlargement  of  the  secretory  glands.  In  decreased  secre- 
tion the  skin  is  smooth  and  transparent  and  free  from  moisture, 
with  an  absence  of  the  pubic  and  axillary  hair. 

Carbohydrate  tolerance  is  a  most  important  symptom, 
especially  from  a  diagnostic  standpoint:  an  increased  carbo- 
hydrate tolerance  is  found  to  be  associated  with  a  deficiency 
of  the  posterior  lobe  secretion^  a  decreased  carbohydrate  toler- 
ance and  glycosuria  are  usually  found  where  there  is  an  in- 
crease in  the  secretion  of  the  posterior  lobe.  The  polyuria 
associated  with  disorders  is  probably  due  to  an  increased  secre- 
tion of  the  posterior  lobe.  Polyuria  and  glycosuria  occurring 
after  cranial  injury,  according  to  Cushing,  are  due  largely  to 
disturbed  activity  or  injury  of  the  pituitary  body.  Variations 
of  the  temperature  occur  in  many  cases.  A  subnormal  tempera- 
ture generally  occurs  together  with  other  symptoms  that  are 
characteristic  of  hypopituitarism.  Blood-pressure  changes  are 
also  common,  a  low  blood-pressure  and  slow  pulse  occurring  in 
hypopituitarism . 

Psychic  disturbances  are  present  in  many  patients;  thus  with 
an  increased  secretion  there  may  occur  restlessness,  wakefulness, 
inattention,  uncertainty,  irritability,  and  varying  grades  ©f 
intellectual  development;  with  hypopituitarism  there  occur 
more  or  less  drowsiness,  intellectual  slowness,  and  at  times 
irritability  and  varying  degrees  of  intellectual  development; 
a  psychosis  varying  in  severity  may  occur  in  either  condi- 
tion. 

Symptoms  due  to  gross  physical  alteration  of  the  pituitary 
gland  may  also  occur.    These  symptoms  are  divided  into  two 


DISORDERS    OF    THE    PITUITARY    BODY  6oi 

groups:  The  first  group  is  caused  by  a  disturbance  of  intra- 
cranial pressure,  giving  rise  to  symptoms  of  general  increased 
cranial  pressure;  of  these,  headache  is,  the  most  common  and 
important  symptom;  choked  disc  is  present  in  a  number  of 
cases.  Venous  stasis  may  also  be  present,  as  manifested  by 
fulness  and  tortuosity  of  the  small  and  large  veins  of  the  fore- 
head and  scalp,  vomiting,  mental  slowness,  drowsiness,  con- 
vulsive seizures,  etc. 

A  second  group  of  symptoms  may  also  occur,  due  to  direct 
irritation  and  compression  or  destruction  of  the  structures  in 
the  immediate  vicinity  of  the  pituitary  body.  Bitemporal 
headache,  which  is  severe  and  persistent,  but  which  may  cease 
after  a  time,  is  a  ver\'  characteristic  s\Tnptom.  Photophobia 
associated  with  deep  orbital  discomfort  and  sensitiveness  of  the 
eyes  on  pressure  is  another  frequent  complaint. 

x-RsLj  examination  of  the  sella  turcica  may  reveal  deformities 
or  marked  alterations.  Atrophy  of  the  optic  ner\'e  may  occur 
early,  and  disturbance  of  vision  and  distortion  of  the  visual 
field  are  common.  Neighborhood  symptoms  can  be  demon- 
strated ver}^  early  in  most  cases  in  which  enlargement  of  the 
pituitars'  body  occurs. 

Abnormal  pupillar}'  conditions,  oculomotor  palsy,  nystagmus, 
and  s}Tnptoms  pointing  to  irritation  or  destruction  of  the  tem- 
poral lobes  are  also  frequently  observed.  Mental  s}Tnptoms 
pointing  to  irritation  or  destruction  of  the  frontal  lobes  are 
present  in  some  cases.  A  fact  to  be  emphasized  is  that  epileptic 
seizures  may  be  among  the  early  and  constant  symptoms  of 
this  disease. 

Course. — The  course  of  the  condition  depends  a  great  deal 
upon  the  cause  of  the  pituitarv'  disease.  In  those  cases  in  which 
there  is  a  perversion  of  the  glandular  secretion  dating  back  to 
early  life,  the  course  is  generally  chronic  and  slowly  progressive; 
in  those  cases  due  to  tumor  the  course  is  usually  slowly  pro- 
gressive, depending  upon  the  rapidity  of  growth  of  the  timior. 
In  cases  due  to  injurv^  or  in  those  following  infectious  diseases 
with  secondarv^  involvement  of  the  gland  the  onset  is  either  acute 
or  subacute,  the  severity  of  the  symptoms  depending  upon  the 
extent  of  involvement  of  the  gland.     In  this  latter  group  of 


6o2  MANUAL   OF   NERVOUS   DISEASES 

cases  the  condition  is  usually  progressive  for  a  time,  after  which 
the  symptoms  may  either  disappear  entirely  or  remain  more  or 
less  permanently  present. 

Prognosis. — The  prognosis  depends  to  a  great  extent  upon  the 
cause.  In  those  cases  in  which  the  disease  is  due  to  a  perversion 
of  the  secretions,  either  in  early  life  or  in  adult  life,  the  outlook 
as  to  recovery  is  unfavorable.  In  these  cases  the  disease  lasts 
many  years,  the  patient  dying  from  an  intercurrent  disease  or 
of  a  progressive  weakness  and  cachexia.  In  those  cases  in  which 
the  disease  is  due  to  a  tumor  the  outlook  is  also  unfavorable, 
owing  to  the  difficulties  surrounding  operative  interference, 
and  to  the  impossibility  of  completely  removing  the  growth 
without  also  destroying  the  gland. 

In  cases  due  to  injury  or  inflammatory  conditions  of  the  gland 
the  outlook  is  somewhat  more  favorable;  in  many  cases  there  is 
a  spontaneous  disappearance  of  the  symptoms,  and  in  others 
there  is  only  a  partial  interference  with  the  activities  of  the 
gland,  and  the  disease  is  thus  present  only  in  a  milder  form. 

Diagnosis. — A  diagnosis  of  a  diseased  state  of  the  pituitary 
gland  can  be  made  only  after  a  very  careful  examination  of  the 
patient,  which  should  include  an  x-ray  examination  of  the  sella 
turcica,  of  the  bones  of  the  face  and  head,  and  of  the  bones 
of  the  extremities.  The  degree  of  carbohydrate  tolerance,  the 
results  of  examination  of  the  eye-grounds  and  field  of  vision, 
together  with  the  history  of  the  changes  in  the  skeletal  growth  or 
of  developmental  disturbances,  premature  or  delayed  develop- 
ment of  the  genital  organs  and  functions,  etc. 

Conditions  arising  from  disturbed  secretion  of  the  pituitary 
must  be  differentiated  from  myxedema,  elephantiasis,  hyper- 
trophic pulmonary  osteo-arthropathy,  osteitis  deformans,  tumors 
of  the  brain  situated  in  other  regions,  and  infantilism  due  to 
other  causes. 

Treatment. — The  treatment  of  diseased  conditions  of  the 
pituitary  gland  is  dependent  upon  the  cause.  In  those  cases  in 
which  the  disease  is  due  to  the  presence  of  a  tumor,  treatment 
is  chiefly  surgical — to  relieve  general  pressure  disturbances 
subtemporal  decompression  is  indicated;  to  relieve  the  symp- 
toms due  to  irritation  or  compression  of  the  neighboring  struc- 


GIGANTISM  603 

tures,  operative  measures  for  the  removal  of  the  growth  are 
indicated. 

In  states  of  hypersecretion  partial  removal  of  the  gland  may 
be  of  benefit,  and  in  cases  of  hyposecretion  transplantation  of 
the  pituitary  glandular  tissue  should  be  attempted. 

Medical  Treatment. — In  those  cases  in  which  there  is  evidence 
of  a  deficient  glandular  secretion  extract  of  the  pituitary  gland 
may  be  tried.  The  administration  of  the  pituitary  extract, 
even  when  given  in  large  doses,  in  these  cases  does  not  always 
improve  the  patient's  condition.  The  extract  of  the  gland  may  be 
given  by  mouth  or  by  hypodermic  injection.  The  administration 
of  the  extract  hypodermically,  either  subcutaneously  or,  better, 
intravenously,  is  more  apt  to  be  followed  by  beneficial  results 
than  when  given  by  the  mouth.  Glandular  transplantation 
may  be  attempted.  Prolonged  exposure  to  the  a:- rays  has  also 
been  recommended  as  controlling  the  advance  of  pituitary 
growths,  and  should  be  used  along  with  surgical  measures. 

GIGANTISM 

This  condition  is  characterized  by  abnormal  growth  of  the 
body,  which  is  usually  accompanied  by  physical  and  mental 
abnormalities,  and  is  due  to  a  h}'"persecretion  of  the  anterior 
lobe  of  the  pituitary  body  occurring  before  puberty. 

Etiology. — In  some  cases  the  gigantism  foUow^s  infectious 
diseases,  intoxications,  trauma,  tumors  of  the  brain,  etc.  Many 
cases  occur  for  which  no  apparent  cause  can  be  found.  The 
disease  occurs  more  frequently  in  males  than  in  females. 

Sjmiptoms. — The  most  striking  s}Tnptom  of  this  disease  is 
the  excessive  size  of  the  body  (Fig.  159).  This  increase  in  the 
size  of  the  body  always  begins  before  adolescence,  and  some- 
times in  very  early  childhood.  These  individuals  may  reach 
a  height  of  nine  or  ten  feet,  but  are  usually  not  taller  than  seven 
feet.  Along  with  the  abnormality  of  size  a  number  of  different 
symptoms  may  occur.  In  some  cases  muscular  weakness  exists; 
in  some  there  is  an  infantile  development  of  the  genitalia;  in 
others  there  is  abnormal  development  of  the  genitalia,  with 
premature    sexual    manifestations.    The    mentality    of    these 


6o4 


MANUAL   OF   NERVOUS   DISEASES 


Fig.  159. — A,  Gigantism  and  acromegaly;   B,  normal;    C,  note  shape  of 

hands  in  patient  A. 

patients  may  be  below  normal.     In  addition  to  these  symptoms 
there  may  be  headache,  visual  disturbances,  epilepsy,  polyuria. 


ACROMEGALY  605 

glycosuria,  increased  carbohydrate  tolerance,  etc.  In  gigantism 
after  the  period  of  adolescence  there  may  occur  changes  that  are 
characteristic  of  acromegaly;  usually  these  changes  take  place  in 
successive  periods,  but  occasionally  the  pathologic  changes  that 
give  rise  to  these  two  conditions  may  take  place  simultaneously. 

Course. — This  disease  usually  runs  a  chronic  course.  In  some 
few  cases  the  onset  is  acute,  and  the  course  may  be  somewhat 
rapid. 

Prognosis. — The  prognosis  is  grave.  The  condition  is  usually 
progressive,  the  individual  generally  dying  from  some  inter- 
current disease,  particularly  pulmonary  tuberculosis.  In  a 
few  cases  the  condition  may  become  spontaneously  arrested. 

Diagnosis. — ^The  diagnosis  is  made  from  the  abnormal  size 
of  the  individual,  the  delayed  or  abnormal  genital  development, 
the  presence  usually  of  mental  retardation  and  of  headache, 
visual  disturbances,  etc. 

Treatment. — ^Treatment  is  very  unsatisfactory.  In  cases  in 
which  a  tumor  or  an  enlarged  pituitary  body  is  present  surgical 
measures,  such  as  subcellular  or  subtemporal  decompression, 
partial  removal  of  the  gland,  etc.,  may  be  tried,  as  may  also 
prolonged  exposure  of  the  pituitary  gland  to  the  .T-rays. 

ACROMEGALY 

This  disease,  w^hich  has  been  expecially  described  by  Marie 
in  1886,  is  characterized  by  an  enlargement  which  involves 
both  the  soft  and  the  bony  structures  of  the  distal  ends  of  the 
limbs,  face,  etc. 

Etiology. — Heredity  seems  to  play  a  part,  but  certainly  not 
an  important  one,  in  the  causation  of  this  disease.  Injury, 
infectious  diseases,  emotional  disturbances,  chronic  intoxica- 
tions, etc.,  have  all  been  assigned  as  etiologic  factors.  Males 
and  females  are  affected  about  equally.  The  condition  occurs 
most  commonly  in  young  adults  and  in  middle  life.  It  is  con- 
ceded now  almost  universally  that  this  disease  is  due  to  a  dis- 
eased condition  of  the  pituitary  gland. 

Pathology. — The  affected  bones  show  a  thickening  of  the 
periosteum,  new  formation   of   periosteal  bone,  and  thicken- 


6o6 


MANUAL   OF   NERVOUS   DISEASES 


ing  of  the  tendinous  and  aponeurotic  insertions.  Conditions 
resembling  arthritis  deformans  are  present  in  the  joints.  The 
skin  covering  the  affected  parts  is  thickened  and  hypertrophied. 
The  subcutaneous  tissues,  glands,  vessels,  etc.,  also  show  a 


Fig.  i6o. — Acromegaly — jc-ray  of  skull  of  patient  shown  in  Fig.  i6i. 
Notice  enlarged  sella  turcica,  prominent  frontal  ridge,  and  projecting  lower 
jaw. 

hypertrophy   and    the    thymus    is    sometimes    enlarged.     The 
thyroid  gland   is  usually  small,  atrophied,  or  shows  goiterous 
degeneration. 
The  most  persistent  change  found  is  the  involvement  of  the 


ACROMEGALY 


607 


pituitary  gland.  This  is  usually  hypertrophied  and  swollen,  or 
a  tumor  of  the  gland  may  be  present.  H}'pertrophy  or  tumor 
of  the  gland  may  cause  irritation  or  compression  of  the  adjacent 
parts  of  the  brain,  erosion,  and  enlargement  of  the  cella  turcica, 
etc.  (Fig.  160). 

Symptoms. — The  disease  is  usually  of  insidious  onset.  There 
is  generally  noticed  at  first  an  enlargement  of  the  hands,  feet, 
and  face;  the  fingers  become  thickened  and  swollen,  and  the 
entire  hand  becomes  thicker  and  larger  than  normal,  this  en- 
largement involving  both  the  bones  and  the  soft  parts.  In 
some  cases  the  bones  of  the  wrist  also  become  affected.     Sim.ul- 


Fig.  161. — Acromegaly — front  and  side  view  of  face  and  hands. 

taneously  the  feet  show  a  similar  enlargement.  The  enlarge- 
ment of  the  hands  may  bring  about  either  of  two  characteristic 
appearances — the  hand  may  become  broad,  the  fingers  not  being 
elongated;  or,  in  addition  to  the  increased  width  of  the  hand,  the 
fingers  become  very  much  elongated  (Fig.  161). 

The  long  bones  of  the  extremities  are  not  markedly  involved, 
so  that  the  hands  and  feet  are  out  of  proportion  to  the  remainder 
of  the  extremities.  The  skin  is  thick  and  hard,  does  not  pit 
on  pressure,  and  is  usually  moist.  The  openings  of  the  sebaceous 
and  sweat-follicles  become  enlarged.  The  head  may  also  be- 
come affected;  generally  the  circumference  of  the  skull  is  in- 


6o8  MANUAL   OF   NERVOUS   DISEASES 

creased,  and  the  external  occipital  protuberance  becomes 
strikingly  prominent.  The  bones  of  the  face  are  particularly 
affected;  the  condition  of  the  lower  jaw  is  characteristic:  it 
becomes  enlarged  and  thickened,  and  projects  beyond  the  upper 
jaw,  especially  in  the  midline  (prognathism) ;  the  entire  face 
becomes  elongated,  marked  thickening  taking  place  in  the  frontal 
bones,  and  giving  rise  to  very  prominent  orbital  ridges  and 
zygomatic  arches,  etc.  The  eyelids  and  lips  become  thickened: 
the  lower  lip  is  heavy  and  everted;  the  tongue  is  broad  and  thick, 
and  sometimes  of  enormous  size;  the  mucous  membranes  are 
frequently  hypertrophied ;  the  palate  and  larynx  are  usually 
hypertrophied,  and  the  voice  is  deep  and  coarse.  The  vertebral 
column,  clavicles,  and  sternum  are  also  generally  affected. 
The  vertebrae  of  the  inferior  cervical  and  superior  dorsal  regions 
become  enlarged  and  thickened,  and  kyphosis  in  this  region  is 
generally  present  to  a  marked  degree.  The  sternum  is  broad 
and  thickened,  and  the  ensiform  process  is  especially  prominent. 
The  ends  of  the  clavicles  are  enlarged,  elevated,  and  thickened. 
The  ribs  and  patellae  may  also  be  affected.  In  some  instances 
the  patient's  entire  body  undergoes  enlargement,  giving  rise  to 
a  condition  in  which  both  gigantism  and  acromegaly  are  present. 
A  condition  resembling  arthritis  deformans  is  sometimes  seen. 

In  some  cases  the  disease  is  ushered  in  with  symptoms  of 
cerebral  tumor;  in  other  cases  these  occur  only  late,  or  not  at 
all.  Polyuria  and  glycosuria  are  frequently  present,  either 
early  or  at  the  close  of  the  disease.  Menstrual  disturbances, 
headache,  may  occur  early  or  not  until  late  in  the  disease, 
disorders  of  vision,  disturbances  of  the  field  of  vision,  optic 
atrophy,  choked  disc,  ocular  palsies,  exophthalmos,  trifacial 
neuralgia,  etc.,  may  occur  during  the  course  of  this  condition. 
Epilepsy  has  been  but  rarely  observed. 

The  abdominal  and  thoracic  organs  are  at  times  hypertrophied, 
and  in  some  cases  dyspnea,  cardiac  palpitation,  and  attacks  of 
syncope  may  give  rise  to  considerable  discomfort.  The  mam- 
mary glands  and  uterus  may  be  enlarged  or  atrophied.  The 
male  or  female  genitalia  may  be  enlarged  or  undego  retro- 
gressive changes.  Sterility  is  frequent,  and  very  often  in  males 
impotence  is  present.    Pain  may  or  may  not  be  a  distressing 


ACROMEGALY  609 

symptom;  it  is  generally  present,  however,  and  in  some  cases  is 
of  a  neuralgic  character.  Pain  in  the  muscles  may  occasion 
great  distress,  and  paresthesias,  especially  in  the  hands,  are 
frequently  present.  The  reflexes  may  be  normal,  increased,  or 
diminished.  The  movements  of  the  patient  are  usually  heavy 
and  awkward;  as  a  rule,  the  individual  lacks  energy  and  is 
drowsy  and  mentally  slow. 

Course.— The  deformity  generally  develops  slowly.  The 
symptoms  referable  to  tumor  of  the  pituitary  gland  may  be  of 
rapid  development  or  may  appear  only  very  slowly.  As  a  rule, 
the  general  health  of  the  individual  suffers.  The  disease  may 
run  a  very  protracted  course,  lasting  many  years,  with  periods 
during  which  there  is  an  apparent  improvement  or  arrest  of 
the  condition.  In  some  few  cases  the  course  of  this  disease 
may  be  very  much  more  rapid. 

>  Prognosis. — The  disease  usually  lasts  many  years,  the  patient 
dying  of  an  intercurrent  affection.  The  outlook  for  the  arrest 
of  symptoms  seems  to  be  somewhat  more  favorable  if  proper 
operative  procedures  are  instituted  early. 

Diagnosis. — In  advanced  cases  the  diagnosis  is  made  without 
difficulty;  it  is  only  in  the  early  stages,  when  there  is  but  slight 
if  any  enlargement  of  the  bones  and  soft  parts,  that  the  diag- 
nosis presents  much  difhculty. 

In  the  early  stages  this  disease  must  be  differentiated  from 
myxedema  and  cretinism;  in  these  diseases  there  is  a  loss  of  hair, 
the  skin  is  cold  and  dry,  there  is  no  involvement  of  the  bony 
parts,  and  a  deposit  of  peculiar,  fat-like  substances  is  seen  in 
the  supraclavicular  and  axillary  spaces;  in  acromegaly  the  skin 
is  moist,  there  is  no  loss  of  hair,  bony  changes  are  present,  and 
there  is  no  deposit  of  fat-like  substance  in  the  neck  or  in  the 
axillary  spaces. 

Acromegaly  and  gigantism  are  closely  related,  and  a  combina- 
tion of  the  two  conditions  takes  place  in  many  instances.  Both 
are  probably  due  to  the  same  cause,  the  one  condition  developing 
before  adolesence,  whereas  the  other  develops  after  adolescence. 
In  either  condition  changes  that  are  characteristic  of  the  one 
disease  may  occur  in  the  other. 

From  elephantiasis  acromegaly  is  distinguished  by  the  fact 
39 


6io 


maniTal  of  nervous  diseases 


that  in  the  former  disease  only  the  skin  and  cellular  tissues  are 
involved,  and  the  disease  affects  only  one  side  or  one  entire  limb. 
From  osteitis  deformans  the  disease  is  differentiated  by  the  fact 
that  in  the  former  disease  the  legs  are  principally  affected, 
whereas  the  hands  and  feet  are  unaffected,  and  the  soft  parts 
show  no  changes;  moreover,  this  disease  generally  appears  after 
the  age  of  fifty.  From  hypertrophic  osteo-arthropathy  (Marie) 
this  disease  is  differentiated  by  the  following  signs : 


Osteo-arthropathy 

The  increase  in  size  affects  mainly 
the  bones. 

The  carpometacarpal  joints  are 
generally  affected. 

The  lower  jaw  is  normal;  ky- 
phosis, if  present,  affects  the  lower 
segment  of  the  spinal  column. 

This  condition  usually  develops 
in  patients  suffering  from  prolonged 
pulmonary  or  cardiovascular  dis- 
ease, etc. 


Acromegaly 

The  increase  in  size  affects  both 
the  soft  parts  and  the  bones. 

The  carpometacarpal  joints  are 
generally  unaffected. 

The  lower  jaw  is  always  involved, 
and  kyphosis  affects  the  cervico- 
dorsal  segment  of  the  spinal  column. 

These  diseases  are  not,  as  a  rule, 
present. 


Fig.  162. — Hands  in  osteo-arthropathy. 

x-Ray  examinations  always  reveal  characteristic  deformities 
of  each  disease. 


INFANTILISM  6ll 

Treatment. — xA.s  this  disease  is  believed  to  be  due  to  an  over-* 
secretion  of  the  anterior  lobe  of  the  pituitary  gland,  the  object 
of  treatment  is  to  bring  about  a  lessened  secretion  of  the  gland. 
The  administration  of  thyroid  extract,  of  atropin,  of  mercury, 
and  of  the  iodids  may  all  be  tried.  Operative  procedures  for 
the  removal  of  parts  of  the  gland  may  be  instituted;  when  under- 
taken by  surgeons  who  have  the  required  training  the  operation 
may  be  performed  with  a  reasonable  degree  of  safety. 

INFANTILISM 

Infantilism  is  a  condition  that  is  characterized  by  the  absence 
of  or  delayed  development  of  the  primary  sexual  characteristics 
(that  is,  a  delay  or  an  absence  in  the  development  of  the  genital 
organs),  and  an  absence  of  or  delayed  development  of  the  sec- 
ondary sexual  characteristics  (that  is,  the  changes  in  the  body 
and  mind  that  usually  occur  as  the  individual  passes  from  child- 
hood into  adult  life;  for  example,  the  figure  loses  its  childish 
contour,  and  the  characteristic  peculiarities  of  the  male  or  female 
appear;  the  voice  changes,  there  is  an  increased  growth  of  hair 
in  the  pubic  and  axillary  regions,  and  changes  in  the  individual's 
emotional  and  intellectual  nature  take  place) . 

''Failure  of  the  primary  and  secondary  sexual  characteristics 
to  appear  at  the  proper  time  constitutes  infantilism;  this  is 
equally  so  whether  the  general  bodily  growth  be  diminutive, 
normal,  or  gigantic." 

Etiology. — In  most  cases  the  underlying  cause  exists  from 
birth  or  early  infancy;  in  some  instances  the  condition  begins 
during  later  childhood,  and  in  a  few  cases  a  retrogression  of  the 
sexual  characteristics  sets  in  in  adult  life.  Among  the  possible 
causes  of  this  condition  is  a  defective  development  of  the  vascular 
system  in  general.  Cases  due  to  this  condition  are  generally 
alluded  to  as  of  the  Lorain  type,  and  were  described  by  Lorain 
in  1 87 1. 

Chronic  infectious  or  other  diseases,  drugs,  intoxications, 
etc.,  such  as  chronic  tuberculosis,  either  in  the  parents  or  in  the 
patient,  congenital  syphilis,  malaria,  pellagra,  heart  disease, 
severe  nutritional  disorders,  alcohol,  lead,  morphin,  tobacco, 


6l2 


MANUAL   OF   NERVOUS   DISEASES 


mercury,  etc.,  which  interfere  seriously  with  the  general 
nutrition  of  the  subject,  give  rise  to  the  cachectic  form  of  in- 
fantilism. 


Fig.  163. — Front  and  side  view  of  a  case  of  infantilism.     Notice  adiposity 
and  infantile  genital  development,  age  twelve  years. 

There  is  a  third  group  of  causes  which  may  give  rise  to  this 
condition.  These  causes  are  dependent  upon  gross  lesions, 
defects,  or  interference  with  the  functions  or  secretions  of  im- 


INFANTILISM 


613 


portant  organs  or  glands;  of  these,  the  most  important  is  defi- 
ciency in  the  secretion  of  the  thyroid  gland,  the  posterior  lobe 
of  the  pituitary,  less  commonly  of  other  ductless  glands,  the 
pancreas,  liver,  etc. 


Fig.  164. — a;-Ray  of  skull  in  infantilism. 

turcica. 


Notice  abnormally  small  sella 


Pathology. — ^As  the  result  of  a  deficient  secretion  of  these 
glands,  there  is  a  lack  of  development  of  the  genital  organs  and 
an  absence  of  the  changes  that  take  place  in  the  body  in  normal 
development  from  infancy  to  childhood,  childhood  to  puberty, 


6 14  MANUAL   OF   NERVOUS   DISEASES 

etc.  In  infantilism,  therefore,  the  genital  organs  are  very  small, 
the  general  physical  contour  is  that  of  a  child,  hair  fails  to 
appear  in  the  axillae  or  on  the  pubes,  menstruation  is  absent, 
the  skin  is  usually  soft,  the  individual  is  generally  plump,  etc. 
(Figs.  163,  164). 

Diminutive  size  is  not  necessarily  present,  as  infantilism 
associated  with  gigantism  is  not  uncommon;  on  the  other  hand, 
diminutive  size  with  normal  primary  and  secondary  sexual 
development  frequently  takes  place. 

Symptoms. — The  condition  is  characterized  by  the  absence 
of  genital  development,  the  genital  organs  being  very  small.  As 
the  individual  grows  older,  in  the  female  the  mammary  glands 
fail  to  enlarge,  hair  does  not  appear  in  the  pubic  or  axillary 
regions,  and  menstruation  does  not  occur;  in  the  male  the  geni- 
talia remain  small,  and  hair  does  not  appear  in  the  pubic  or 
axillary  region  or  on  the  face.  The  intelligence  may  be  fairly 
normal  or  remain  child-like  and  immature.  There  is  usually  a 
marked  retardation  in  the  bodily  development,  the  physique 
usually  remaining  diminutive  and  resembling  that  of  a  young 
child.  There  are,  of  course,  exceptions  to  this  condition,  and 
in  these  there  may  be  abnormal  growth  of  the  body,  giving 
rise  to  gigantism. 

In  addition  to  the  delayed  or  absent  primary  and  secondary 
sexual  characteristics,  many  symptoms  occur  that  are  dependent 
upon  the  causative  condition. 

Course. — ^This  condition  is  usually  very  slowly  progressive. 
There  is  noticed  in  these  individuals  a  delayed  and  deficient 
physical,  mental,  and  genital  development. 

Prognosis. — ^The  prognosis  in  most  cases  is  rather  unfavorable. 
If  due  to  deficient  thyroid  secretion,  and  if  treated  before  ado- 
lescence has  occurred,  the  outlook  is  favorable.  If  it  is  due  to 
disease  of  the  pituitary  body,  the  prognosis  depends  upon  the 
possibility  of  removing  the  cause,  which  is  that  of  pituitary 
disease  in  general. 

Diagnosis. — It  is  important  to  differentiate  the  various 
types  of  infantilism,  so  that  proper  treatment  can  be  instituted. 
This  can  be  done  only  by  going  carefully  into  the  history  of  the 
case,  and  making  careful  examinations  to  discover  the  presence 


DISORDERS    OF    THE    PINEAL    GLAND  615 

of  diseased  conditions  and  abnormal  states  of  the  secretions  of 
the  ductless  glands.  It  is  also  important  to  differentiate  in- 
fantilism from  such  conditions  as  achondroplasia,  lack  of  men- 
tal development  due  to  organic  cerebral  disease  or  to  lack 
of  cerebral  development.  These  latter  conditions  are  differ- 
entiated from  infantilism  by  the  fact  that  in  them  normal 
development  of  the  sexual  organs  is  generally  present. 

Treatment. — It  is  most  important,  in  these  cases,  to  look  after 
the  general  health  of  the  individual;  to  treat  any  of  the  possible 
causes  that  may  give  rise  to  a  cachectic  state.  If  the  condition 
is  due  to  deficient  thyroid  secretion,  the  treatment  is  the  same 
as  that  of  cretinism;  that  is,  administration  of  thyroid  gland 
extract,  beginning  with  small  doses,  and  gradually  increasing 
them  until  the  physiologic  effect  of  the  drug  has  been  produced, 
then  discontinuing  the  remedy  for  a  few  days,  and  gradually 
resuming  the  treatment  with  smaller  doses. 

In  cases  in  which  deficient  secretion  of  the  pancreas  is  a 
probable  cause,  the  effect  of  the  administration  of  pancreatic 
extract  is  to  be  tried.  In  those  cases  in  which  the  pituitary 
gland  is  at  fault  one  may  try  the  administration  of  the  extract 
of  this  gland.  In  all  cases  in  which  a  probable  cause  cannot 
be  ascertained  it  is  well  to  administer  thyroid  extract. 

A  nutritious  diet  should  be  ordered,  and  the  patient  should 
be  instructed  to  drink  sufficient  water.  The  bowels  should  be 
regulated,  and  physical  exercise  be  prescribed  in  accordance 
with  the  needs  and  physical  condition  of  the  individual. 

DISORDERS   OF  THE   PINEAL   GLAND 

The  functions  of  the  pineal  gland  have  not  as  yet  been  defi-i 
nitely  determined.  There  is  still  quite  a  diversity  of  opinion 
as  to  whether  the  gland  possesses  a  definite  function  or  whether 
it  is  the  remains  of  an  embryonic  structure.  Most  authorities 
believe  that  the  gland  has  definite  functions  that  are  active 
during  early  life,  and  that,  after  adolescence,  these  functions  are 
gradually  lost.  The  gland  is  believed  to  secrete  a  substance 
that  enters  the  blood  and  that  has  an  influence  on  normal  growth 
and  on  the  development  of  sexual  maturity. 


6i6 


MANUAL   OF   NERVOUS   DISEASES 


Pathologic  States  of  the  Pineal  Gland. — In  addition  to  local  or 
general  cerebral  manifestations,  diseased  conditions  of  the 
pineal  gland  usually  give  rise  to  the  following  symptoms:  An 
abnormal  rate  of  growth,  with  a  premature  sexual  maturity; 


Fig.  165. — Case  of  pineal  gland  syndrome,  boy  thirteen  years  old,  5  feet 
6f  inches  in  height.  Notice  adult  genital  developement,  etc.  This  patient 
has  had  epileptiform  seizures  since  second  year. 

the  increase  in  size  is  symmetric,  and  corresponds  to  that  which 
occurs  under  normal  conditions  in  an  older  individual;  i.  e.,  as 
if  normal  physical  and  sexual  maturity  were  attained  with  an 
abnormal  degree  of  rapidity  and  at  a  prematurely  early  age 
(Figs.  165  and  166). 


DISORDERS    OF    THE   PINEAL   GLAND 


617 


Evidence  of  ahnormal  size  and  premature  sexual  maturity 
appears  at  a  very  early  age.  Epilepsy  occurs  in  many  cases. 
The  intellectual  development  may  be  normal  for  the  age  or 
retarded;  it  is  very  rarely  above  normal. 

The  course  is  usually  slow,  the  first  evidence  appearing  within 
the  first  few  years  of  life.    The  symptoms  are  slowly  progressive, 


Fig.  166. — .t-Ray  showing  normal  sella  turcica  in  patient  shown  in  Fig.  165, 


the  patient  dying  either  of  some  intercurrent  disease  or  as  the 
result  of  the  local  pathologic  condition  bringing  about  a  dis- 
turbance of  intracranial  pressure  and  subsequent  death. 

The  prognosis  is  extremely  grave.  In  most  cases  the  condition 
is  gradually  progressive,  death  occurring  before  the  twentieth 
year;  in  some  cases  it  occurs  during  the  first  few  years  of  life. 


6l8  MANUAL   OF   NERVOUS   DISEASES 

If  the  condition  is  due  to  a  tumor  in  the  neighborhood  of  the 
pineal  gland,  operative  procedures  may  possibly  avert  a  fatal 
outcome,  but  the  operation  itself  is  very  difficult,  and,  except  in 
the  hands  of  the  most  expert,  is  usually  followed  by  a  fatal 
outcome. 

The  diagnosis  is  made  from  the  presence  of  an  abnormal  rate 
of  growth,  unattended  by  abnormalities  of  bone  and  muscle 
development.  The  increase  in  stature  is  such  as  would  be 
normally  present  in  a  much  older  individual.  There  is  a  pre- 
mature development  of  the  sexual  organs  and  of  the  sexual 
functions.  Mentally  the  individual  is  not  advanced  beyond 
his  age,  and  often  there  is  evidence  of  a  mental  deficiency.  In 
addition  to  these  symptoms  there  may  be  evidences  of  a  cerebral 
tumor  or  of  internal  hydrocephalus.  The  x-ray  may  be  of  help, 
especially  in  diagnosing  calcareous  deposits  that  have  taken 
place  in  the  neighborhood  of  the  pineal  gland.  The  x-ray  fails 
to  reveal  abnormalities  in  the  sella  turcica,  the  bones  of  the  skull 
and  face,  and  the  bones  of  the  extremities,  such  as  occur  in 
gigantism  with  precocious  sexual  development  (Fig.  i66). 

Treatment  is  wholly  surgical.  A  decompression  operation 
may  be  performed  where  there  is  marked  increased  intracranial 
pressure  or  if  choked  disc  exists,  and  operative  attempts  to 
rectify  pathologic  conditions  of  the  pineal  gland  have  also 
been  made. 


DISEASES  DUE  TO  DISTURBANCES  OF  THE 
VASOMOTOR   SYSTEM 

ACROPARESTHESIA 

Etiology. — Exposure  to  cold,  the  frequent  and  prolonged 
immergence  of  the  hands  in  cold  or  in  hot  water,  overuse  of  the 
hands,  etc.,  are  among  the  common  causes  of  this  condition. 
The  disease  occurs  more  frequently  in  women  than  in  men. 
It  usually  occurs  after  the  thirtieth  year,  but  may  appear 
earlier.  It  is  more  apt  to  affect  washenA^omen,  cooks,  seam- 
stresses, etc.  Poor  hygienic  surroundings,  anemia,  chronic 
intoxication,  injury,  grip,  etc.,  have  also  been  mentioned  as 
causes  of  this  condition. 

Pathology. — This  affection  is  probably  due  to  an  interference 
with  nutrition  or  to  an  irritation  of  the  sensory  ner\'e-endings 
in  the  extremities,  caused  by  vasomotor  disturbances.  Such 
disturbances  are  either  due  to  local  conditions,  such  as  prolonged 
exposure  to  cold  or  to  hot  or  cold  water,  toxic  conditions,  etc., 
or  are  of  central  origin,  the  result  of  overv\'ork. 

Symptoms. — ^The  individual  usually  complains  of  paresthesia 
in  the  fingers,  sometimes  extending  to  the  hands.  There  is  a 
feeling  of  burning  and  numbness,  w^hich  is  most  severe  in  the 
tips  of  the  fingers.  In  some  cases  the  patients  complain  of  a 
feeling  of  burning;  others  of  itching,  and  some  of  coldness  and 
stiffness  of  the  fingers.  Pain  may  be  complained  of,  but  is 
usually  not  severe. 

The  paresthesias  are  more  or  fes  cunstantly  presrerrt,  but  they 
vary  in  degree.  As  a  rule,  they  are  more  marked  in  the  mornings, 
immediately  after  arising,  improve  somewhat  during  the  day, 
but  aTe  usually  intensified  upon  exercise  or  exposure.  A  careful 
objective  examination  of  these  individuals  may  show  some 
slight  decrease  of  sensibility  in  the  finger-tips,  but  even  this  is 

619 


620  MANUAL   OF  NERVOUS  DISEASES 

absent  in  many  cases.  Many  of  these  patients  are  of  a  neurotic 
disposition. 

Course. — ^The  affection  usually  develops  very  slowly  and  runs 
a  chronic  course.     It  may  last  for  many  years. 

Prognosis. — Under  proper  treatment  a  complete  disappear- 
ance of  the  symptoms  usually  occurs.  Some  cases  are  very 
resistant  to  treatment  and  persist  for  years.  Relapses  are  very 
apt  to  follow  undue  exposure. 

Diagnosis. — ^A  careful  examination  should  always  be  made  to 
exclude  other  diseases  that  may  begin  with  the  paresthesia;  the 
more  important  of  these  are  tabes  dorsalis,  organic  disease  of 
the  cervical  enlargement  of  the  spinal  cord,  Raynaud's  disease, 
ergotism,  tetany,  hysteria,  multiple  neuritis,  severe  anemias, 
etc. 

Treatment. — It  is  most  important  to  remove  the  cause. 
Overuse  of  the  hands  and  too  free  use  of  cold  and  hot  water, 
etc.,  should  be  avoided.  The  individual's  general  health  should 
be  carefully  looked  after,  and  tonics  containing  iron,  strychnin, 
arsenic,  etc.,  should  be  given.  The  daily  local  application  of 
the  faradic  or  of  the  faradic  and  galvanic  current  seems  to  do 
much  good, 

MIGRAINE    (HEMICRANIA) 

This  disease  is  characterized  by  sudden  attacks  of  intense 
pain  on  one  side  of  the  head,  which  are  frequently  preceded  by 
signs  of  irritation  of  the  various  functions  of  the  brain.  The 
pain  gradually  becomes  worse,  until,  when  the  greatest  intensity 
is  reached,  there  occur  digestive  disturbances,  with  more  or  less 
prostration,  followed  by  gradual  relief. 

Etiology. — Heredity  is  the  most  important  factor.  According 
to  Mobius,  in  90  per  cent,  of  cases  the  disease  is  directly  in- 
herited. Prolonged  emotional  disturbance,  debilitating  condi- 
tions, excitement,  overwork  under  unfavorable  conditions,  etc., 
may  predispose  or  bring  on  an  attack.  The  disease  may  also  be 
of  reflex  origin:  refractive  errors,  diseases  of  the  generative 
organs,  throat,  nose,  and  accessory  sinuses,  or  of  the  abdominal 
organs,  etc.,  may  either  predispose  to  the  disease  or  bring  on  an 
attack. 


MIGRAINE    (hEMICRANIA)  62 1 

The  disease  manifests  itself  for  the  first  time  usually  during 
early  childhood;  rarely  does  a  first  attack  occur  after  the  eight- 
eenth year.  The  exciting  causes  of  individual  attacks  very 
often  include  excitement,  variations  in  the  atmospheric  pressure, 
excesses  of  any  kind,  such  as  overindulgence  in  eating  or  drink- 
ing, or  overwork,  mental  or  physical. 

Pathology. — A  careful  examination  fails  to  reveal  any  constant 
pathologic  change  either  of  the  centrai  nervous  system  or  in  the 
body.  Two  theories  are  held  regarding  the  causation  of  the 
attacks.  One  is  that  there  is  produced  in  the  body,  either  as 
the  result  of  excitement  or  of  som_e  other  disturbance,  a  toxic 
substance  that  at  first  produces  stimulation  of  the  brain,  causing 
a  sense  of  well-being  and  of  increased  capacity  for  work  and 
exhilaration.  This  is  soon  followed  by  a  secondary  and  more 
lasting  effect,  which  evidences  itself  as  pain  and  depression 
of  the  cerebral  functions ;  further,  as  the  result  of  the  elimination 
of  this  poison  through  the  stomach  and  intestines,  gastro- 
intestinal symptoms  occur,  a  normal  state  of  health  being  again 
attained  after  the  poison  has  been  eliminated.  The  nature  of 
the  toxin  is  still  undetermined.  The  other  theory  is  that  this 
disease  is  of  vasomotor  origin,  and  that  the  symptoms  are  due 
to  a  temporary  localized  interference  with  the  cerebral  circula- 
tion. It  would  appear  as  if  both  of  these  theories  were  correct: 
that  this  disease  occurs  only  in  individuals  who,  as  the  result  of 
a  hereditary  taint,  are  either  susceptible  to  certain  poisons  or 
in  whom  there  is  a  tendency  to  the  formation  of  specific  toxins, 
which  at  first  cause  a  vasomotor  dilatation,  this  being  followed 
in  turn  by  a  vasomotor  spasm.  The  vasomotor  disturbances 
are  more  marked  on  one  side  of  the  brain  than  upon  the 
other.  The  prostration  is  due  either  to  the  effect  of  the 
toxemia  or  to  the  exhaustion  of  the  vasomotor  centers, 
which  have  been  overstimulated ;  the  gastro-intestinal  symp- 
toms are  the  result  of  nature's  efforts  to  eliminate  the  toxic 
substances. 

Symptoms. — In  many  cases  the  attack  is  preceded  by  a 
period  of  excitement  or  by  a  feeling  of  well-being  which  m^ay  last 
for  several  hours  and  sometimes  for  several  days.  In  other 
cases  the  attack  is  preceded  by  a  feeling  of  exhaustion,  drowsi- 


622 


MANUAL   OF   NERVOUS   DISEASES 


ness,  fulness  in  the  head,  depression,  etc.     Again  there  is  another 
group  of  cases  in  which  ocular  migraine  is  generally  preceded 


Fig.  167. — a,  b,  and  c  represent  the  ocular  phenomena  in  the  field  of 
vision  at  different  stages  during  an  attack  of  migraine,  when  the  eyes  are 
closed.  The  central  white  cross  is  the  point  to  which  the  sight  was  directed; 
the  zigzag  lines  and  diffused  coloration  represent  the  scintillating  scotoma 
(Mackinzie,  in  Allbutt's  "System  of  Medicine"). 


for  from  a  few  minutes  to  a  half-hour  by  the  appearance  of 
flashes  of  light,  by  bright  spots,  which  may  be  of  any  color, 


MIGRAINE    (HEMICRANIA)  623 

before  one  or  both  eyes,  and  which  sometimes  gradually  enlarge 
to  form  zigzag  lines  or  fortification  spectra  (Fig.  167).  These 
are  true  visual  hallucinations,  as  they  are  continued  in  the 
dark  or  on  closing  the  eyes.  These  attacks  may  also  be  pre- 
ceded by  a  partial  or  complete  hemianopsia,  and  more  rarely 
by  blindness. 

Either  with  or  without  these  premonitory  signs  the  character- 
istic symptom  of  the  disease — headache — occurs.  The  headache 
does  not,  as  a  rule,  commence  in  its  full  intensity;  it  is  usually 
dull  at  first  and  gradually  grows  worse  until  it  becomes  almost 
unbearable.  It  is  not  generally  limited  to  one  side,  as  the  name 
of  the  disease  would  lead  one  to  suppose,  but  frequently  affects 
the  forehead  and  both  temples.  Pain  is  present  above  the  eyes 
and  in  the  occipital  region,  and  frequently  is  more  intense  at 
one  point,  the  location  of  which  may  vary  at  different  times; 
thus  one  side  of  the  head  may  be  affected  more  severely  than 
the  other,  and  in  some  patients  the  attacks  alternate  from  side  to 
side.  Very  frequently  the  patient  also  complains  of  a  hyperes- 
thesia and  tenderness  of  the  scalp. 

During  the  attack  the  patient  is  abnormally  sensitive  to 
sensory  impressions.  Bright  light  or  noises  intensify  the  pain, 
and  in  order  to  avoid  these  he  remains  in  a  quiet,  darkened 
room.  Movement  of  the  head  also  increases  the  pain,  and 
consequently  the  patient  keeps  as  quiet  as  possible.  During 
the  attack  the  individual  feels  weak,  there  is  a  loss  of  appetite, 
and  vomiting  generally  occurs  at  the  height  or  toward  the  close 
of  the  attack,  at  w^hich  time,  also,  diarrhea  and  pohniria  may 
occur.  Finally,  the  pain  begins  to  decrease  and  the  individual 
falls  asleep,  usually  awaking  free  from  pain  and  considerably 
exhausted,  but  strength  rapidly  returns. 

In  some  cases  vasomotor  and  pupillary  symptoms  occur:  the 
face  may  become  pale,  the  skin  cold,  the  pupils  dilated,  and  the 
temporal  artery  contracted.  In  other  cases  the  face  is  red,  the 
conjunctivae  are  injected,  the  temporal  artery  is  dilated  and 
pulsating,  and  the  pupils  are  contracted.  In  some  few  cases 
speech  disturbances  (such  as  incomplete  aphasia),  paresthesia,  or 
weakness,  limited  to  one  limb  or  to  the  side  of  the  body  opposite 
to  that  on  which  the  most  pain  is  experienced,  occur. 


624  MANUAL   OF   NERVOUS   DISEASES 

In  some  subjects  the  attacks  are  limited  to  pain  in  the  head, 
prostration,  and  gastro-intestinal  symptoms;  in  others  these 
symptoms  are  accompanied  by  signs  of  irritation  or  by  depression 
of  localized  cerebral  areas.  The  intensity  of  the  individual 
attack  may  vary.  No  definite  periodicity  of  these  attacks  is 
seen — they  recur  at  irregular  intervals,  especially  after  excite- 
ment or  following  mental  or  physical  indiscretions;  in  women 
they  may  occur  every  three  or  four  weeks,  in  these  cases  bearing 
some  relation  to  menstruation.  Occasionally  the  attacks  may 
be  very  mild  and  easily  aborted  by  medicine,  occupation,  etc. 

Course. — The  disease  usually  manifests  itself  in  early  child- 
hood and  recurs  in  attacks  at  irregular  intervals  for  many 
years.  In  some  cases  there  is  a  tendency  for  the  disease  to 
disappear  in  later  adult  life. 

In  many  cases  when  the  individual  has  passed  middle  life,  if 
complete  relief  does  not  occur,  the  vomiting  and  the  ocular 
symptoms  disappear.  This  disease  is  often  associated  with 
neurasthenia  and  hysteria,  and  symptoms  of  these  neuroses  are 
often  present  during  the  intervals  between  the  attacks. 

Prognosis. — ^The  prognosis  in  each  individual  attack  is,  of 
course,  good,  there  being  practically  no  danger  to  life,  although 
the  prostration  may  be  extreme.  The  attacks  usually  last  for 
from  twenty-four  to  seventy-two  hours,  rarely  longer. 

With  proper  treatment  and  regulation  of  the  patient's  life 
the  intervals  between  attacks  can  be  greatly  lengthened,  and  in 
some  cases  the  attacks  entirely  prevented.  In  most  cases  the 
migraine  appears  at  irregular  intervals,  finally  becoming  less 
severe,  and  often  disappearing  entirely  after  the  fiftieth  year. 
Attacks  also  disappear  during  pregnancy,  and  sometimes  when 
the  patient  changes  his  mode  of  living,  or  lives  amid  different 
climatic  conditions,  changes  his  occupation,  etc.  These  in- 
dividuals usually  become  prematurely  aged  and  gray.  In  a 
very  small  number  of  cases  the  migraine  attacks  cease  and 
epilepsy  develops. 

Diagnosis. — The  diagnosis  of  this  condition,  as  a  rule,  presents 
very  little  difficulty.  It  must  be  differentiated  from  hysteria, 
cerebral  tumor,  meningitis,  toxemias,  etc.  Any  difficulty  that 
may  arise  is  present  only  in  the  first  attacks.    The  condition 


MIGRAINE    (hEMICRANIA)  625 

is  differentiated  from  hysteria  by  the  fact  that  in  the  latter 
disease  the  individual  usually  does  not  wish  to  be  alone;  the 
pain  is  rarely  limited  to  the  head;  the  vomiting  occurs  early, 
and  the  patient  is  amenable  to  suggestion;  in  migraine,  on  the 
other  hand,  the  individual  wishes  to  be  left  alone,  because  light, 
sound,  and  movement  tend  to  increase  the  pain;  he  appears 
weak,  and  the  vomiting  occurs  toward  the  close  of  the 
attack. 

In  cerebral  tumor  the  pain  is  more  or  less  constantly  present, 
the  pulse  is  usually  slow,  and  ophthalmoscopic  examination 
frequently  shows  fundus  changes;  irritative  symptoms,  when 
present,  persist  for  a  time,  and  then,  as  succeeding  portions  of 
the  brain  become  affected,  gradually  merge  into  paralytic 
symptoms. 

From  meimigitis  the  condition  is  differentiated  by  the  physical 
signs  of  meningitis  and  the  examination  of  the  cerebrospinal 
fluid.  From  cerebral  syphilis  migraine  is  differentiated  by  the 
history,  the  examination  of  the  blood  and  the  spinal  fluid,  and 
the  effect  of  the  treatment;  from  toxemias,  either  of  gastro- 
intestinal or  of  nephritic  origin,  a  careful  physical  and  clinical 
examination  should  render  the  diagnosis  comparatively  certain. 
When  the  attacks  have  recurred  at  irregular  interv^als  for  any 
length  of  time,  particularly  in  the  presence  of  a  history  of  a 
similar  condition  in  the  ancestry,  the  diagnosis  is  compara- 
tively simple.  It  should  be  remembered  that  individuals  who 
are  subject  to  migraine  may  also  acquire  organic  diseases,  and 
therefore  whenever  an  attack  occurs  that  is  accompanied  by 
symptoms  of  an  unusual  nature,  or  that  is  unduly  persistent,  a 
careful  examination  should  be  made  to  determine  that  no  other 
condition  has  developed  in  addition  to  the  migraine. 

Treatment. — ^The  treatment  of  this  condition  should  be 
directed  toward  improving  the  general  health  of  the  patient,  so 
as  to  prevent  a  recurrence  of  the  attacks,  or  to  lengthen  the 
intervals  between  attacks.  Relief  of  the  individual  attacks  is 
also  indicated. 

General  Treatment. — The  person  who  is  subject  to  attacks  of 
migraine  should  lead  a  simple  life,  free  from  excitement,  avoiding 
both  mental  and  physical  overexertion;  he  should  follow  some 
40 


626  MANUAL   OF   NERVOUS   DISEASES 

congenial  occupation.  Undue  exposure  to  either  too  hot  or  too 
cold  weather  should  be  avoided,  and,  if  possible,  he  should  live 
in  some  mild,  stimulating  climate;  if  this  is  not  possible,  he 
should  so  regulate  his  attire  as  to  meet  weather  conditions. 
The  diet  should  be  light,  nutritious,  and  non-stimulating;  all 
food  should  be  thoroughly  masticated  before  it  is  swallowed, 
and  it  is  better  for  the  patient  to  eat  four  small  meals  a  day  than 
two  or  three  large  meals.  Heavy  pastries,  rich  foods,  and  alco- 
holic drinks  are  best  avoided.  The  patient  should  drink  at  least 
two  quarts  of  water  a  day.  The  bowels  should  be  regulated, 
and  under  no  condition  should  constipation  be  allowed  to  occur. 
Exercise  in  moderation  is  to  be  encouraged,  but  physical  fatigue 
or  sports  in  which  excitement  plays  a  part  should  be  avoided. 
The  patient  should  spend  as  much  time  as  possible  out-of-doors j 
and  should  rest  for  a  short  time  after  each  meal. 

Bathing. — Hot  alkaline  baths,  followed  by  cold  sponges,  hot 
baths,  or  Turkish  baths  once  a  week,  are  all  beneficial.  The 
Scotch  douche,  taken  each  morning  upon  arising,  is  also  helpful 
in  improving  the  general  tone  of  the  patient.  A  course  of  treat- 
ment at  Carlsbad  is  helpful  in  many  cases.  Massage,  properly 
given,  is  of  much  service.  Physical  defects,  such  as  errors  of 
refraction,  diseases  of  the  throat  and  nose,  and  abdominal  and 
pelvic  disorders  should  receive  proper  treatment,  if  possible, 
corrected.  If  anemic,  patients  should  be  given  preparations  of 
iron  and  arsenic,  and  in  many  instances  it  is  well  also  to  give 
strychnin  in  proper  doses.  Starr  has  found  the  administra- 
tion of  thyroid  extract  of  considerable  service.  Bromids  given 
in  small  doses  are  often  of  advantage  to  those  of  a  nervous 
temperament. 

Treatment  of  the  Attack. — In  the  milder  cases  it  is  occasionally 
possible  to  abort  the  attacks  by  washing  out  the  stomach  with 
an  alkaline  solution;  in  other  cases  this  may  be  done  by  the 
administration  of  a  saline  purgative,  and  at  times  by  the  ap- 
plication of  an  ice-cap  or  of  a  hot-water  bottle  to  the  head, 
and  also  by  the  prompt  administration  of  drugs,  such  as  a  large 
dose  of  the  bromids,  or  a  capsule  containing  aspirin,  5  grains; 
caffein  citrate,  i  grain;  camphor  monobromate,  J  grain;  and 
codein  sulphate  \  grain ;  this  capsule  may  be  repeated  within 


MIGRAINE    (hEMICRANIA)  627 

one-half  hour,  and  then  every  two  hours,  until  four  or  five 
capsules  in  all  have  been  taken.  At  times  the  patient  will 
cease  to  respond  to  aspirin,  but  will  react  to  phenacetin,  pyr- 
amidon,  etc.  In  some  patients  a  cup  of  hot  strong  coffee  will 
abort  the  attack;  again  some  individuals  obtain  relief  from 
the  administration  ofly^-g-  grain  of  nitroglycerin.  If  these  pro- 
cedures are-  not  successful  in  aborting  the  attack,  the  patient 
should  be  placed  in  a  quiet,  darkened  room,  one  that  is  well 
ventilated  and  kept  cool.  It  is  well  to  apply  ice-caps  to  the 
head  and  hot-water  bottles  to  the  feet.  The  nausea  may  be 
relieved  by  mustard  plasters  or  other  counterirritants  applied 
to  the  epigastric  region.  In  the  early  stages  the  coal-tar  prod- 
ucts, combined  with  codein,  caifein,  camphor  monobromate, 
nitroglycerin,  strychnin,  etc.,  will  lessen  the  pain.  When  the 
nausea  and  vomiting  become  intense,  nothing  is  retained  by 
the  stomach.  During  the  attack  it  is  advisable  to  abstain  from 
all  food.  Liquids  should  be  given  at  frequent  intervals  in 
small  quantities.  It  is  also  well  early  in  the  attack  to  give  a 
saline  purgative  if  this  can  be  retained;  if  this  is  impossible, 
calomel  may  be  tried;  this  may  be  given  in  one  single  dose  of 
2  grains,  or  in  eight  doses  of  j  grain  each,  given  at  intervals  of 
fifteen  minutes.  If  the  lower  bowel  contains  much  fecal  mat- 
ter, a  hot  soapsuds  enema  should  be  given. 

in  those  cases  that  are  not  benefited  by  any  of  the  foregoing 
measures  a  h}^odermic  injection  of  morphin  may  be  given; 
this  should,  however,  be  used  only  under  exceptional  conditions, 
as  there  is  great  danger  in  these  cases  of  creating  the  morphin 
habit ;  moreover,  the  administration  of  morphin  certainly  exerts 
an  unfavorable  effect  on  metabolism,  thereby  predisposing  the 
patient  to  more  frequent  attacks.  Most  patients  sooner  or 
later  succeed  in  finding  some  drug  or  some  procedure  that  affords 
them  relief;  or,  finding  that  nothing  seems  to  give  relief,  they 
refuse  all  medicines  during  the  attack,  preferring  to  remain 
quietly  in  a  darkened  room,  taking  only  a  small  amount  of 
liquid  nourishment,  and  bearing  the  pain  with  patience  until  the 
attack  has  passed  off. 


628  MANUAL   OF  NERVOUS   DISEASES 

ERYTHROMELALGIA 

Erythromelalgia,  or  red  neuralgia,  is  a  condition  that  was 
first  described  by  Wier  Mitchell.  It  is  characterized  by  pain, 
swelling  and  redness  of  the  skin  of  the  distal  parts  of  the  feet, 
of  the  hands,  or  of  all  four  extremities. 

Etiology. — This  is  a  somewhat  uncommon  affection.  Men  are 
more  frequently  affected  than  women.  Exposure  to  cold  seems 
to  be  the  principal  predisposing  cause.  Nothing  definite  is 
known  as  to  the  true  cause  of  this  condition. 

Pathology.— The  disease  has  been  described  as  an  angioneu- 
rosis;  as  an  affection  of  the  vasomotor  centers;  as  a  diseased 
condition  of  the  spinal  cord.  In  one  case  Wier  Mitchell  found 
marked  degeneration  of  the  fine  nerve  branches  of  the  peripheral 
nerves.  The  most  constant  findings  are  pathologic  states  of  the 
smaller  peripheral  arteries.  In  the  opinion  of  Barlow,  Buerger, 
and  others,  in  erythromelalgia  we  have  a  disease  in  which  there 
is  an  affection  of  the  smaller  vessels  of  the  extremities,  resulting 
in  disturbance  of  circulation — in  other  words,  a  condition  that 
is  closely  related  to  intermittent  claudication.  The  alternating 
states  of  coldness  and  hyperemia,  pallor,  blueness,  and  redness, 
may  be  explained  by  varying  degrees  of  spasms  and  dilatations 
of  the  arteries  that  have  to  do  with  the  collateral  circulation. 
The  pain  in  these  conditions  may  be  due  to  the  spasms  of  the 
arteries  themselves,  to  disturbances  of  the  circulation  of  the 
nerves,  or  to  muscular  cramps;  to  what  extent  any  one  of  these 
factors  enters  into  the  production  of  pain  it  is  difficult  to  say. 

Symptoms. — Pain  is  the  most  marked  symptom.  This  may 
come  on  suddenly,  and  sometimes  follows  overexertion.  The 
pain  occurs  in  the  feet,  especially  in  the  balls  of  the  toes  and  in 
the  heels,  or  in  the  hands  and  fingers,  or  in  all  four  extremities. 
The  pain  is  accompanied  by  redness,  which  is  most  marked  in 
the  distal  portions  of  the  affected  extremities.  With  the  redness 
there  is  usually  slight  swelling.  The  patient  complains  of  a 
feeling  of  heat.  The  blood-vessels  generally  pulsate,  and  there 
is  a  slight  objective  rise  of  the  skin  temperature,  and  frequently  a 
local  hyperidrosis  occurs.  Sensibility  is  not,  as  a  rule,  affected. 
The  redness,  swelling,  and  pain  vary  in  intensity.    The  pain  is 


Raynaud's  disease  (symmetric  gangrene)      629 

generally  severe,  and  may  increase  to  such  an  extent  as  to  be 
practically  unbearable;  it  is  somewhat  relieved  by  elevating  the 
extremities.  Cold  applications  also  afford  some  relief  from 
pain,  whereas  heat  increases  it.  In  some  cases  the  congestive 
appearance  becomes  so  marked  that  the  hands  or  the  feet,  or 
the  hands  and  the  feet,  take  on  a  dark  purplish  color.  In  ad- 
dition to  the  local  symptoms  there  may  be  headache,  vertigo, 
general  weakness,  and  cardiac  complications. 

A  careful  physical  examination  usually  fails  to  reveal  any 
causative  condition. 

Course  and  Prognosis. — There  is  no  treatment  known  that 
seems  to  affect  the  course  of  the  condition.  The  disease  may 
begin  suddenly  or  gradually  and  remain  more  or  less  constantly 
present;  at  times  there  are  temporary  remissions.  The  condi- 
tion is  a  very  distressing  one,  and  the  pain  may  become  so 
severe  that  there  is  danger  of  the  patient  attempting  suicide. 

Treatment. — Cold  applications  and  elevation  of  the  affected 
parts  seem  to  afford  some  relief.  Operations  for  the  removal  of 
the  nervTS  are  at  times  resorted  to,  and  in  some  instances 
amputation  has  been  necessary.  The  various  drugs  for  the 
relief  of  pain  may  be  used.  It  may  be  necessary^  at  times  to 
resort  to  general  anesthesia  in  order  to  afford  relief,  and  careful 
supervision  of  the  patient  be  necessary  to  prevent  suicide. 

RAYNAUD'S   DISEASE    (SYMMETRIC   GANGRENE) 

This  disease  is  characterized  by  hyperemia  or  ischemia,  occur- 
ring and  terminating  more  or  less  suddenly,  in  symmetric  parts 
of  the  body,  especially  in  the  phalanges  of  all  the  extremities. 
It  may  or  may  not  result  in  trophic  changes  or  in  gangrene. 

Etiology. — Heredity,  as  evidenced  by  the  occurrence  of 
neuroses  in  the  ancestry  and  of  a  neuropathic  disposition,  is 
present  in  many  cases. 

The  disease  occurs  most  frequently  between  the  fifteenth 
and  the  thirtieth  year,  but  it  may  occur  in  very  young  children 
and  in  older  persons.  Females  are  more  prone  to  be  affected 
than  males. 

Anemia,  exhaustion,  trauma,  overexercise,  infectious  diseases, 


630  MANUAL   OF  NERVOUS   DISEASES 

such  as  influenza,  typhoid,  erysipelas,  pneumonia,  etc.,  chronic 
diseases  of  the  kidneys,  heart,  and  blood-vessels,  chronic  poison- 
ing by  lead  and  alcohol,  diseases  of  the  genital  organs,  exposure 
to  cold,  and  emotional  disturbances,  are  all  believed  to  be  among 
the  predisposing  causes.  Certain  occupations  seem  to  predispose 
to  the  condition;  thus  washerwomen,  waitresses,  and  chamber- 
maids constitute  the  class  most  often  affected.  Marked  emo- 
tional disturbances  seem  to  occur  very  frequently  before  the 
onset  of  the  disease.  Many  cases  are  seen  in  which  it  is  impos- 
sible to  discover  a  probable  cause. 

A  symmetric  gangrene  may  also  occur  during  the  course  of 
certain  nervous  diseases,  such  as  hysteria,  tabes  dorsalis,  syrin- 
gomyelia, multiple  sclerosis,  tumors  of  the  spinal  cord,  epilepsy, 
exophthalmic  goiter,  traumatic  neuroses,  dementia  praecox, 
myelomalacia,  etc. 

Pathology. — ^The  nature  of  the  disease  is  still  undetermined. 
Some  investigators,  among  them  Raynaud,  held  that  this  dis- 
ease was  of  central  origin,  the  dilatations  and  contractions  of  the 
vessels  being  due  to  an  abnormal  process  going  on  in  the  vaso- 
motor centers  in  the  spinal  cord.  Other  investigators  believe 
that  the  vasomotor  conditions  are  the  result  of  a  reflex  irritation 
arising  in  the  periphery  or  brain,  this  irritation  affecting  the 
vasomotor  centers  and  thus  bringing  about  the  vascular  dis- 
turbances. Still  others  claim  that  the  primary  disease  affects 
the  blood-vessel  walls  and  the  nerve-endings  in  the  vessels.  As 
the  result  of  some  pathologic  process  there  develops  a  condition 
of  the  arterioles  that  may  vary  in  degree  from  partial  to  complete 
occlusion,  resulting  in  paleness  or  cyanosis,  which  may  be  of 
temporary  duration,  or  which  may  be  followed  by  gangrene  of 
the  affected  part,  depending  upon  the  extent  and  the  duration 
of  the  interference  with  the  blood-supply.  In  other  cases  spasm 
of  the  smaller  veins  may  occur,  bringing  about  redness,  which 
may  be  followed  in  turn  by  gangrene.  The  spasm  of  the  vessels 
may  begin  and  end  suddenly. 

Symptoms. — In  practically  all  cases  in  which  the  manifes- 
tations of  this  disease  occur  independently  of  other  nervous 
affections,  the  onset  is  sudden.  In  some  few  cases  the  local 
symptoms  are  preceded  by  general  constitutional  disturbances, 


Raynaud's  disease  (symmetric  gangrene)      631 

the  individual  becoming  irritable,  restless,  and  depressed. 
Headache,  loss  of  appetite,  and  gastro-intestinal  disturbances 
may  occur;  then,  more  or  less  suddenly,  the  local  symptoms 
develop.  The  attack  usually  commences  with  paresthesia,  a 
feeling  of  numbness  or  deadness,  a  burning  or  tingling,  which 
finally,  as  a  rule,  develops  into  a  marked  painful  state  of  the 
fingers  and  toes.  The  paresthesia  and  the  pain  may  be  present 
for  days  or  weeks  preceding  the  attack,  and  may  increase  with 
its  onset. 

Hyperesthesia  or  h}^o-esthesia  may  be  present  during  the 
early  stages  of  the  attack.  Either  following  or  preceding  the 
paresthesia  and  pain  there  is  an  ischemia  of  the  affected  ex- 
tremity. The  further  course  of  the  attack  depends  upon  the 
extent  and  duration  of  the  vascular  occlusion;  in  the  first  stages 
the  fingers  and  toes  become  white  and  cold,  like  those  of  a  dead 
person,  and  the  prick  of  a  pin  is  not  followed  by  bleeding.  Along 
wdth  this  condition  there  is  usually  violent  pain.  In  som_e  cases 
the  interference  with  the  circulation  is  not  quite  so  complete; 
there  is,  as  a  rule,  some  impairment  of  sensation,  the  finer 
movements  become  clumsy,  and  actual  anesthesia  may  exist. 
The  affected  parts  become  shrunken,  and  the  skin  is  thro'v^ii  into 
folds  and  is  somewhat  hard  and  immovable.  The  secretion  of 
sweat  may  be  increased  or  entirely  suspended,  and  the  local 
temperature  is  lowered.  The  duration  of  the  attack  varies  from 
a  few^  moments  to  several  days.  The  spasm  may  relax  suddenly, 
and  the  part  return  to  the  normal  condition,  the  return  of  the 
blood,  as  a  rule,  being  accompanied  by  a  burning  sensation. 
This  first  stage  may  be  followed  by  a  cyanosis,  or  the  cyanosis 
may  exist  from  the  onset.  The  cyanosis  results  either  from  a 
complete  arterial  spasm,  in  which  case  the  venous  blood  re- 
gurgitates into  the  capillaries  and  distends  them,  or,  as  the 
result  of  a  venous  spasm,  there  occurs  a  congestion  of  the  part, 
the  blood  in  the  capillaries  finally  becoming  venous  and  thus 
producing  the  cyanotic  appearance.  In  some  cases  the  stage 
of  ischemia  is  so  short  as  to  pass  unnoticed,  and  the  patient's 
attention  is  first  attracted  by  the  swollen,  blue,  and  painful 
condition  of  the  affected  part. 

Stage  of  Cyanosis, — The  affected  parts  appear  blue  and  swollen, 


632 


MANUAL   OF   NERVOUS   DISEASES 


are  frequently  infiltrated,  feel  cool,  and  are  generally  hyperes- 
thetic.  Severe  pain  is  present.  The  parts  can  usually  be  moved. 
When  this  condition  persists  the  parts  become  blue-black  and 
finally  black,  and  the  epidermis  may  show  vesicles  and  slight 
hemorrhages.     Even  with  this  condition  there  may  be  a  sudden 


Fig.  168. — Raynaud's  disease,  showing  spontaneous  amputation  of  fingers 
and  toes;  areas  of  gangrene  (case  of  Dr.  Arthur  Shipley). 


relaxation  of  the  spasm  and  the  parts  resume  their  normal  ap- 
pearance, although,  as  a  rule,  this  is  slower  than  after  simple 
ischemia.  This  second  stage  may  last  from  a  few  seconds  to 
several  days,  and  is  usually  followed  by  gangrene. 


Raynaud's  disease  (symmetric  gangrene)      633 

The  third  stage,  or  stage  of  gangrene,  is  always  preceded  by 
cyanosis.  In  the  cyanotic  areas  small  blisters  filled  with  bloody 
serum  appear;  these  soon  rupture,  then  dry,  and  dark  crusts 
form,  beneath  which  ulceration  takes  place.  In  some  cases  the 
gangrene  is  limited  to  the  superficial  tissues  and  the  ulcer  heals 
over.  In  other  cases  the  ulceration  may  involve  the  deeper 
structures,  which  may  gradually  granulate  and  heal.  In  still 
other  cases  the  entire  skin  of  a  terminal  phalanx  may  become 
black  and  dry  and  undergo  gangrene.  Gangrenous  involve- 
ment of  an  entire  phalanx  is  the  exception  rather  than  the  rule. 
The  dead  tissue  is  bounded  by  a  line  of  demarcation.  With  the 
completion  of  the  stage  of  gangrene  the  local  symptoms  terminate. 
It  is  the  symmetric  distribution  of  the  local  symptoms  which  is 
characteristic  of  the  disease;  thus  the  fingers  of  both  hands,  toes 
of  both  feet,  more  or  less  s}Tnmetrically  situated  spots  upon  the 
forearms,  arms,  legs,  thighs,  and  trunk  are  affected,  singly  or  in 
combination  (Fig.  168).  In  many  cases  the  fingers  and  toes  are 
chiefly  affected,  only  a  few  spots  occurring  on  the  body;  very 
often  the  toes  escape.  The  face  is  frequently  affected,  spots  of 
cyanosis  appearing  on  the  nose,  ears,  or  lips. 

As  a  rule,  the  gangrene  affects  only  the  tips  of  the  extremities 
and  small  areas  of  skin  on  the  forearm  or  arm.  In  addition  to 
the  characteristic  s^onptoms  of  s}Tnmetric  gangrene,  other 
manifestations  occur :  in  some  cases  there  is  atrophy  of  the  small 
muscles  of  the  hand,  or  trophic  disturbances  of  the  nails  and 
skin  occur.  Trophic  disturbances,  with  swelling,  redness,  and 
effusion  of  the  joints;  visual  disorders  attributed  to  spasms  of 
the  retinal  arteries;  deafness,  tinnitus  aurium,  and  disturbance 
of  the  sense  of  taste,  etc.,  may  occur  as  transient  s}Tnptoms. 
Oculomotor  and  pupillary  disturbances,  temporary  albuminuria, 
glycosura,  transient  aphasia,  epilepsy,  and  paralysis  of  cerebral 
origin  may  also  occur.  Mental  disorders,  such  as  depression, 
excitement,  confusion,  etc.,  may  precede  or  accompany  the 
attack. 

Course. — ^The  onset  of  an  attack  is  usually  sudden.  The 
symptoms  of  the  first  two  stages,  that  is,  the  symptoms  of 
ischemia  and  of  the  stage  of  cyanosis,  may  last  for  only  a  few 
minutes  and  pass  off,  or  the  first  stage  last  a  short  time,  the 


634  MANUAL   OF   NERVOUS   DISEASES 

second  stage  longer,  and  then  the  symptoms  disappear;  or  the 
second  stage  may  be  long  or  short  and  terminate  in  gangrene. 

As  a  rule,  the  first  and  second  stages  last  several  days,  and 
the  stage  of  gangrene  continues  for  several  weeks.  In  some 
individuals  the  disease  is  limited  to  a  single  attack ;  in  others  re- 
currences occur  within  a  year,  the  disease  lasting,  with  remissions, 
for  several  years,  and  in  some  cases  for  many  years. 

If  the  gangrene  begins  simultaneously  in  all  the  affected  parts, 
the  duration  will  be  shorter  than  if  it  extends  from  one  part  to 
another.  The  attacks  may  rapidly  succeed  each  other,  or 
there  may  be  a  prolonged  interval  between  attacks.  Some 
attacks  are  very  much  more  severe  than  others.  Moderate 
vasomotor  disorders  are  usually  present  during  the  intervals 
between  the  attacks. 

Prognosis. — It  is  impossible  to  state  with  certainty  whether 
or  not  a  recurrence  of  the  attacks  will  take  place,  nor  can  one 
state  with  positiveness  that  recovery  from  the  individual  attack 
is  to  be  expected.  The  duration  of  tlie  attack  depends  upon  the 
character,  the  extent,  and  the  severity  of  the  symptoms.  Life 
is  not  endangered  by  this  disease. 

Diagnosis. — Raynaud's  disease  must  be  differentiated  from 
frost-bite.  In  frost-bite  there  is  usually  a  history  of  exposure 
together  with  itching  and  burning  that  are  persistent:  in.  Ray- 
naud's disease  the  attack  occurs  suddenly  without  exposure, 
and  usually  pain,  more  or  less  marked,  is  present,  which  ceases 
when  the  vascular  spasms  subside.  From  ergot  poisoning 
Raynaud's  disease  is  to  be  differentiated  by  the  history.  From 
gangrene  occurring  in  hysteric  and  neuropathic  individuals  Ray- 
naud's disease  is  differentiated  by  the  presence  of  other  symptoms 
of  the  hysteric  and  neuropathic  states,  and  the  lack  of  symmetry 
in  the  distribution  of  the  gangrenous  areas.  From  gangrene 
occurring  in  diabetes,  in  nephritis,  in  old  age,  in  endarteritis,  in 
spinal  cord  diseases,  in  leprosy,  etc.,  Raynaud's  disease  is  to  be 
differentiated  by  the  history  and  by  careful  examination. 

The  diagnosis  of  Raynaud's  disease  rests  practically  upon  the 
development  of  the  vasomotor  symptoms  in  the  extremities  or 
on  the  trunk,  situated  in  symmetrically  situated  areas,  the 
symptoms  going  on  to  gangrene.      The  condition  occurs  usually 


Raynaud's  disease  (symmetric  gangrene)      635 

in  individuals  between  the  fifteenth  and  the  thirtieth  year,  and 
is  accompanied  by  pain,  which  is  more  or  less  severe,  but  which 
passes  off  as  the  arterial  spasm  relaxes.  In  Raynaud's  disease 
there  is  no  history  of  exposure  to  cold  or  to  ergot-poisoning,  and 
there  is  an  absence  of  endarteritis,  nephritis,  diabetes,  spinal 
cord  disease,  leprosy,  etc. 

Treatment. — ^The  general  health  of  the  patient  must  be  looked 
after.  Tonics  and  proper  hydro  therapeutic  measures  are  in- 
dicated. The  bowels  should  be  kept  well  open,  the  diet  regu- 
lated, and  excitement,  worry,  exposure  to  cold,  and  indulgence 
in  alcoholic  drinks  are  to  be  avoided.  Between  the  attacks  the 
treatment  should  be  directed  to  the  general  building  up  of  the 
body  and  of  the  nervous  system.  During  an  attack  if  the  pain 
is  very  severe  it  should  be  relieved  by  codein  or  morphin.  If 
restlessness  is  marked,  the  bromids  or  the  bromids  and  chloral 
should  be  given.  The  patient  should  be  kept  quiet,  and  the 
affected  parts  should  be  protected  by  enveloping  them  in  soft 
bandages  or  cotton.  In  no  case  should  irritating  ointments  or 
the  faradic  current  be  used  on  these  parts. 

During  the  attack  gentle  massage,  dry  heat,  or  lukewarm 
hand-  and  foot-baths  may  give  relief.  Galvanism  to  the  spine 
has  often  been  tried  and  is  to  be  recommended,  but  the  faradic 
current  should  never  be  used.  A  moderately  weak  galvanic 
current  may  be  tried,  placing  the  positive  pole  over  the  cervical 
region  and  the  negative  pole  over  the  lumbar  region ;  the  treat- 
ment should  last  for  about  ten  minutes  and  should  be  employed 
once  daily;  the  current  should  not  be  strong  enough  to  cause 
much  discomfort.  The  galvanic  current  may  also  be  used  on 
the  affected  extremities,  the  positive  pole  being  placed  over  the 
spinal  column,  and  the  negative  pole  being  gently  moved  back- 
ward and  forward  over  the  extremities,  care  being  taken  to  use 
weak  currents  and  to  turn  the  current  on  and  off  gradually. 
It  has  also  been  recommended  that  the  affected  Jimbs  be  kept 
warm  by  covering  them  with  cotton  and  bandages,  and  placing 
them  at  rest  in  an  elevated  position.  If  gangrene  occurs,  the 
parts  are  to  be  kept  surgically  clean.  All  local  injury  and 
counterirritation  are  to  be  carefully  avoided. 

Residence  in  a  w^arm  climate,  such  as  southern  California, 


636  MANUAL  OF  NERVOUS  DISEASES 

Florida,  or  Cuba,  will  generally  prevent  a  recurrence  of  at- 
tacks and  rapidly  cause  a  disappearance  of  all  symptoms. 

ANGIONEUROTIC  EDEMA  (ACUTE  CIRCUMSCRIBED 

EDEMA) 

Etiology. — This  condition  generally  affects  persons  of  a 
nervous  disposition.  It  often  occurs  in  combination  with 
hysteria,  neurasthenia,  and  urticaria.  Various  intoxications, 
especially  of  intestinal  origin,  exposure  to  cold,  excitement, 
emotional  disturbances,  and  injury  are  regarded  as  exciting 
causes.  Nervous  or  toxic  disturbances  occurring  at  the  men- 
strual period  may  bring  on  the  condition. 

It  generally  occurs  in  young  adults,  but  not  uncommonly 
affects  children. 

Pathology. — The  nature  of  the  condition  has  as  yet  not  been 
established.  A  local  venous  spasm  or  local  secretion  of  lymph 
has  been  regarded  as  a  probable  cause. 

Symptoms. — ^Attacks  of  acute  circumscribed  edema  may  come 
on  with  or  without  preceding  emotional  disturbance,  exposure 
to  cold,  etc.  There  usually  occurs,  more  or  less  suddenly,  a 
circumscribed  edematous  swelling  of  the  skin  and  sometimes  of 
the  mucous  membrane.  These  swellings  are  rounded  or  may  be 
irregular  in  outline;  they  may  develop  in  different  parts  of  the 
body  or  affect  one  entire  extremity,  one  side  of  the  face,  etc. 
The  swellings  stand  out  prominently  on  the  skin,  and  are  either 
much  redder  or  much  paler  than  the  surrounding  skin.  The 
temperature  of  these  swellings  is  somewhat  lower  than  that  of 
the  surrounding  tissues. 

The  condition  appears  to  be  of  the  nature  of  an  edema  of  the 
superficial  tissues.  The  swelling  is  hard,  does  not  pit  on  pres- 
sure, and  cannot  be  completely  removed  by  pressure  or  manipiT- 
lation.  These  swellings  are  usually  accompanied  by  a  sensation 
of  stiffness.  If  they  occur  about  the  eyelids,  the  mouth,  or  the 
extremities,  motion  is  somewhat  impeded.  Burning,  numbness, 
and  even  actual  pain  at  times  accompany  these  swellings.  The 
discomfort  is  usually  increased  by  the  application  of  cold.  The 
swellings  generally  occur  in  paroxysms,  which  come  on  more  or 
less  suddenly  and  last  for  from  a  few  hours  to  several  days. 


ANGIONEUROTIC   EDEMA  637 

In  the  majority  of  cases  there  is  a  complete  cessation  of  the 
symptoms  between  the  attacks.  The  tongue,  Hps,  larynx, 
pharynx,  conjunctiva,  cheeks,  joints,  gastro-intestinal  tract, 
kidneys,  etc.,  may  be  the  seat  of  the  edema.  As  a  rule,  the 
general  health  is  not  affected,  but  the  swelling  of  the  mucous 
membrane  may  give  rise  to  troublesome  symptoms.  In  in- 
dividuals suffering  from  this  condition  periodic  attacks  of 
vomiting,  gastro-intestinal  pain,  asthma,  interference  with 
breathing,  etc.,  may  occur. 

Course. — The  disease  usually  begins  suddenly  in  the  form  of 
paroxysms,  which  may  occur  frequently  or  only  at  inter\^als.  It 
generally  runs  a  prolonged  course;  relapses  are  ver>'  common. 

Prognosis. — ^Life  is  seldom  in  danger.  Recovery  from  in- 
dividual attacks  is  to  be  expected,  and  usually,  after  a  consider- 
able period,  there  may  be  complete  freedom  from  further  attacks. 
In  many  instances  the  condition  lasts  for  years. 

Diagnosis. — This  condition  must  be  differentiated  from  urti- 
caria. This  can  usually  be  done  by  a  careful  consideration  of 
the  histor}^  of  the  case,  and  by  the  fact  that  in  urticaria  the 
lesions  are  much  smaller  and  do  not  occur  simultaneously,  but 
successively.  An  intense  burning  and  itching  is  present  in 
urticaria  and  absent  in  acute  edema;  furthermore,  cold  applica- 
tions usually  afford  relief  in  urticaria,  but  aggravate  the  condi- 
tion in  acute  edema. 

From  chronic  hereditary  trophic  edema  and  from  permanent 
edema  the  condition  is  differentiated  by  the  fact  that  in  these 
diseases  the  swelling  is  present  more  or  less  permanently,  and 
the  edema  is  due  to  a  true  hj-pertrophy  of  the  tissues. 

Treatment. — The  most  important  factor  in  the  treatment 
consists  in  improving  the  general  health  of  the  patient  and 
building  up  the  nervous  system  by  proper  exercise,  food,  hydro- 
therapy, rest,  massage,  and  mental  training.  The  diet  should  be 
regulated,  and  the  bowels  kept  well  open.  Care  should  be  taken 
to  avoid  undue  exposure  to  cold  and  emotional  disturbances. 

Internally,  arsenic,  atropin,  quinin,  and  str}^chnin  have  all 
been  used  with  advantage.  If  one  remedy  fails,  another  should 
be  tried.  Irritating  or  cold  lotions  and  applications  should 
be  carefully  avoided. 


TROPHONEUROSES 

PROGRESSIVE   FACIAL  HEMIATROPHY 

This  condition  is  characterized  by  a  progressive  decrease  in 
size  of  one  side  of  the  face,  the  atrophy  involving  both  the  soft 
and  the  hard  tissues.  Along  with  the  atrophy  there  is  a  marked 
pigmentation  of  the  skin. 

Etiology. — ^This  disease  is  very  rare,  and  occurs  most  fre- 
quently between  the  tenth  and  the  twentieth  year.  Injury  of 
the  face  or  skull,  operations  upon  the  throat,  infectious  diseases, 
such  as  diphtheria,  erysipelas,  measles,  pneumonia,  and  a  con- 
genital predisposition  are  believed  to  be  among  the  causative 
agents. 

Pathology. — By  some  this  disease  is  attributed  to  a  pathologic 
condition  originating  in  the  Gasserian  ganglion  or  in  the  sym- 
pathetic system,  the  atrophy  being  regarded  as  a  secondary 
trophic  condition ;  other  authorities  consider  this  to  be  a  primary 
atrophy  of  the  cutaneous  and  subcutaneous  cellular  tissue. 

Symptoms. — This  disease  generally  begins  with  the  appearance 
of  atrophy  in  one  or  more  parts,  especially  in  the  orbital  region 
and  the  lower  jaw.  There  is  a  discoloration  of  the  skin,  which 
gradually  becomes  glossy  and  undergoes  atrophic  changes. 
This  is  followed  by  a  wasting  of  the  subcutaneous  tissues  and 
the  disappearance  of  the  fatty  tissue.  The  skin,  which  may  be 
pale,  brown,  yellow,  or  bluish  in  color,  falls  into  folds,  and  finally 
lies  close  to  the  bones;  gradually  the  bony  structures  become 
affected  and  decrease  in  size.  The  process,  which  usually  starts 
in  one  or  two  places,  may  remain  limited  to  these  parts  for  some 
time,  or  they  may  gradually  extend  until  all  the  tissues  upon  one 
side  of  the  face  are  involved;  eventually,  as  the  result  of  this 
process,  there  is  a  decrease  in  size  in  every  part  of  one  side  of  the 
638 


PROGRESSIVE   FACIAL    HEMIATROPHY  639 

face;  the  bones  in  particular  become  smaller,  and  the  asymmetry 
is  very  evident.  The  eye  is  usually  deeply  sunken,  and  the  cheek 
furrowed  and  grooved.  In  the  advanced  stage  the  difference 
between  the  two  sides  of  the  face  is  very  striking;  the  atrophy 
affects  the  skin,  subcutaneous  tissues,  bones,  and  sometimes  the 
muscles  of  the  face  and  tongue.  Occasionally  the  larynx  has 
been  involved.  The  hair  is  rarely  affected,  for  the  atrophy 
seldom  extends  to  the  scalp.  Occasionally  the  atrophy  extends 
to  the  other  side  of  the  face,  and  may  even  involve  the  shoulder, 
girdle,  or  one  entire  side  of  the  body.  Sensory  disturbances  are 
uncommon.  Herpes  may  exist.  The  secretion  of  the  sebaceous 
glands  is  diminished;  the  perspiration  may  be  increased;  the 
temperature  of  the  skin  is  normal. 

Electric  examination  of  the  muscles  shows  no  reaction  of 
degeneration.  Paralysis  does  not  occur,  although  w^eakness  may 
exist.  The  teeth  and  the  eyebrow^s  are  usually  involved  and 
may  fall  out. 

Course. — This  disease  is  slowly  progressive,  but  sooner  or 
later  comes  to  a  standstill.  In  association  with  this  condition 
it  is  not  uncommon  to  observe  neuralgia,  tabes  dorsalis,  epilepsy, 
facial  tic,  disseminated  sclerosis,  psychosis,  chorea,  palsy  of  the 
ocular  muscles,  pupillary  disturbances,  etc. 

Prognosis. — The  disease  is  usually  slow^ly  progressive,  in 
rare  instances  extending  to  the  opposite  side  of  the  face  or  in- 
volving the  neck,  shoulder,  or  the  entire  side  of  the  body.  As  a 
rule,  spontaneous  arrest  of  the  condition  takes  place. 

Treatment. — -The  general  health  of  the  patient  should  be 
looked  after,  and  careful  examination  made  for  any  irritative  or 
destructive  disease  of  the  vascular  system,  the  sympathetic,  or 
of  the  Gasserian  ganglion  or  its  branches.  If  any  such  condition 
is  present,  an  attempt  should  be  made  to  correct  the  same. 

Local  disease  of  the  throat  and  nose  should  receive  proper 
treatment.  Local  massage  of  the  affected  side  of  the  face  should 
be  conscientiously  used.  Tonics  containing  strychnin  should 
be  administered.  In  those  cases  in  w^hich  marked  deformity 
exists,  the  symmetry  of  the  face  may  be  somewhat,  if  not  com- 
pletely, restored  by  the  subcutaneous  injection  of  paraffin,  as 
recommended  by  Gersuny  and  others. 


640  MANUAL  OF  NERVOUS  DISEASES 

SCLERODERMA 

This  disease  is  characterized  by  an  abnormal  condition  of 
the  skin  and  subcutaneous  tissues. 

Etiology. — ^Little  is  known  concerning  the  etiology.  Heredity, 
prolonged  emotional  disturbances,  exposure  to  cold,  a  marked 
rheumatic  tendency,  injury,  etc.,  have  all  been  known  to  precede 
this  condition.  It  has  also  been  observed  in  paresis,  tabes 
dorsalis,  and  chronic  spinal  disease.  The  disease  may  occur  at 
any  age,  but  is  most  common  between  the  twentieth  and  the 
fortieth  year.  Women  are  more  frequently  affected  than 
men. 

Pathology. — Almost  all  authorities  regard  scleroderma  as  a 
trophoneurosis.  The  condition  has  also  been  attributed  to 
poisoning  or  disturbance  of  the  internal  secretions. 

Pathologic  examination  of  the  nervous  system  has  revealed 
nothing  definite.  The  disease  is  characterized  by  a  sclerosis 
affecting  the  skin  and  subcutaneous  tissues,  which  is  followed  by 
atrophy  and  contraction.  In  addition  to  the  skin  changes 
degenerative  alterations  in  the  blood-vessels  are  usually  present. 

Symptoms. — For  some  time  before  the  occurrence  of  the 
sclerodermic  process  vasomotor  symptoms  may  occur,  such, 
for  example,  as  local  cyanosis,  redness  and  edema,  and,  at  the 
same  time,  pain,  itching,  tingling,  and  burning.  Either  with 
or  without  these  symptoms  changes  indicative  of  the  disease 
take  place. 

The  process  may  be  circumscribed,  and  take  the  form  of 
spots,  or  may  be  diffuse.  The  spots,  which  at  first  are  isolated 
or  disseminated,  as  a  rule  become  confluent  later  in  the  disease. 

Frequently  some  part  of  the  body  that  has  been  exposed  to 
pressure  serves  as  the  starting-point,  from  which  the  disease 
spreads  to  other  areas — the  face,  the  neck,  and  the  upper  ex- 
tremities are  chiefly  affected;  the  trunk  is  less  often  involved, 
and  the  legs  are  but  seldom  affected.  In  the  earlier  stages  of 
the  disease  edematous  spots  appear;  the  skin  in  these  areas 
becomes  indurated  and  swollen,  has  a  brawny,  thick  feel,  and 
cannot  be  separated  from  the  underlying  tissues.  Gradually 
the  skin  becomes  more  tense,  and  a  disappearance  of  pigment 


SCLERODERMA  64 I 

or  abnormal  pigmentation  takes  place.  At  this  stage  the  skin 
presents  a  glossy,  polished  appearance.  As  the  condition 
progresses  the  veins  become  prominent  and  the  skin  becomes 
thin,  tense  and  cold,  and  is  adherent  to  the  subcutaneous  tissue. 
The  atrophy  may  extend  to  the  deeper  parts,  and  involve  the 
muscles  and  bones.  If  the  hands  are  involved,  the  fingers  be- 
come stiff,  thin,  and  shriveled;  annular  constriction  may  take 
place,  with  spontaneous  amputation  of  the  phalanges.  When 
the  face  is  involved,  the  movements  of  the  facial  muscles  be- 
come restricted,  the  features  are  drawn,  the  face  assumes  a 
mask-like  expression,  the  lips  become  thin  and  stretched,  and 
mastication  and  speech  are  markedly  interfered  with. 

If  the  neck  and  thorax  are  affected,  respiration  may  be 
impeded.  Sensibility  is  practically  never  affected.  Mental 
depression  commonly  occurs,  and  in  severe  cases  general  wasting 
develops.  Scleroderma  may  be  combined  with  other  trophic 
disorders,  particularly  facial  hemiatrophy,  Raynaud's  disease, 
and  erythromelalgia. 

Course. — This  disease  usually  begins  gradually,  being  preceded 
by  paresthesia.  The  affected  areas  are  at  first  isolated,  but 
gradually  they  become  confluent.  In  a  large  majority  of  cases 
the  condition  is  gradually  progressive,  lasting  for  many  years. 

Prognosis. — ^This  disease  usually  terminates  in  death  from 
cachexia  or  from  some  intercurrent  disease. 

Diagnosis. — ^As  a  rule,  there  is  httle  difficulty  in  arriving  at 
a  correct  diagnosis  of  this  disease  if  one  takes  into  consideration 
its  gradual  development  and  its  characteristic  features. 

Treatment. — The  general  health  of  the  patient  should  be 
carefully  supervised.  The  bowels  should  be  kept  freely  open 
and  the  diet  regulated.  General  massage,  galvanism  of  the 
spine,  and  inunctions  of  ichthyol  ointment  should  be  tried. 
Internally,  the  salicylates,  the  iodids,  and  thyroid  and  pituitary 
extract  may  be  tried.  Subcutaneous  injections  of  a  15  per  cent, 
alcoholic  solution  of  thiosinamin,  given  every  other  day,  are 
recommended  by  Hebra.  Local  treatment  with  hot  air  may 
also  be  tried. 

41 


UNCLASSIFIED   DISORDERS 

ACHONDROPLASIA 

This  condition  is  charactenzea  by  a  congenital  smallness  of 
the  stature,  which  is  due  to  a  deficient  ossification  of  the  car- 
tilage of  the  long  bones. 

Etiology. — In  some  instances  the  disease  is  hereditary.  The 
condition  has  been  attributed  to  an  intra-uterine  inflammatory 
affection,  during  the  course  of  which  the  cartilages  at  the  epiph- 
yseal ends  of  the  long  bones  are  destroyed,  and,  as  a  consequence, 
there  is  marked  retardation  in  the  longitudinal  development  of 
these  bones. 

Pathology. — This  condition  is  the  result  of  an  interference 
in  the  growth  of  the  cartilaginous  portion  of  the  skeleton.  This 
interference  with  growth  may  begin  at  different  periods  of  intra- 
uterine life — the  earlier  the  condition  begins,  the  shorter  are 
the  bones.  Bones  surrounded  by  membrane  are  not  involved, 
the  primary  condition  being  a  disturbance  of  cartilage  for- 
mation. 

Symptoms. — ^The  average  height  of  the  achondroplastic  subject 
varies  from  38  to  53  inches.  The  shape  of  the  hand  is  also 
characteristic:  all  the  fingers  are  relatively  of  the  same  length; 
there  is  a  peculiar  separation  of  the  second  and  the  third  finger 
at  the  second  phalangeal  joint  which  causes  the  digits  to  spread 
out,  giving  rise  to  the  so-called  ''trident  hand."  Lumbar 
lordosis  is  present  almost  without  exception.  Cesarean  section 
is  practically  always  necessary  when  labor  occurs  in  an  achon- 
droplastic woman  (Fig.  169). 

Even  during  the  earliest  years  of  life  the  small  size  and  the 

shortness  of  the  limbs  are  noticed.     As  the  individual  becomes 

older  there  is  a  marked  retardation  in  the  growth  of  the  long 

bones,  so  that  the  individual  remains  of  dwarfish  stature.    Cer- 

642 


ACHONDROPLASIA 


643 


tain  peculiarities  are  characteristic  of  this  disease.  It  is  noticed 
that  the  head  is  of  normal  size,  and  is  sometimes  even  larger 
than  normal.     The  trunk  also  closely  approaches  the  normal  in 


Fig.  169. — Achondroplasia,  from  Obstetrical  Clinic,  University  of  Maryland 

Hospital. 


size,  but  is  usually  somewhat  smaller.  The  most  characteristic 
feature  of  the  disease  is  the  fact  that  the  limbs,  that  is,  the  arms 
and  legs,  fail  to  develop  in  their  long  axes — the  arms  are  very 
short  when  the  individual  is  standing  erect;  the  fingers  usually 


644  MANUAL   OF  NERVOUS  DISEASES 

reach  only  to  the  trochanters,  whereas  in  normal  individuals 
they  generally  reach  to  the  lower  third  of  the  thigh;  the  legs  are 
also  abnormally  short.  It  is  further  noticed  that  the  proximal 
ends  of  the  limbs,  that  is,  the  arms  and  the  thighs,  are  retarded 
in  their  longitudinal  growth,  even  to  a  greater  extent  than  are 
the  distal  ends.  The  musculature  is  well  developed;  the  gen- 
italia are  normal  in  size  and  in  function,  and  in  the  majority 
of  cases  the  mentality  is  not  affected. 

Diagnosis. — ^This  condition  must  be  differentiated  from 
rickets,  cretinism,  congenital  syphilis,  etc.  From  rickets  the 
disease  is  differentiated  by  the  fact  that  achondroplasia  is  con- 
genital, the  lesions  being  complete  at  birth;  the  deformities  are 
present,  but  as  the  individual  grows  they  become, exaggerated; 
rickets,  on  the  other  hand,  is  a  postnatal  disease;  furthermore, 
the  ;:t:-ray  aids  in  the  differentiation  of  the  two  diseases:  in 
achondroplasia  the  lesions  are  in  the  cartilage,  and  the  epiphyses 
are  about  normal  in  size;  in  rickets  the  epiphyses  are  enlarged; 
in  achondroplasia  the  head  and  trunk  are  normal,  whereas  in 
rickets  they  are  frequently  affected. 

From  cretinism  this  disease  is  differentiated  by  the  fact  that 
the  mentality  in  achondroplasia  is  normal,  whereas  in  cretinism 
there  is  a  deficiency  in  intelligence;  the  hair  in  achondroplasia  is 
abundant  and  soft,  whereas  in  cretins  it  is  scanty  and  coarse; 
the  x-ray  reveals  the  important  difference  in  the  bones ;  more- 
over, cretins  improve  under  thyroid  extract,  which  has  no  effect 
on  the  achondroplastic  individual. 

From  congenital  syphilis  achondroplasia  can  be  differentiated 
by  x-ray  examination  of  the  bones. 

Course. — ^This  condition  is  present  at  birth,  and  the  de- 
formities are  merely  accentuated  as  the  individual  grows  older. 
The  prognosis  as  to  life  is  good,  but  as  to  bringing  about  a  normal 
growth  of  the  stature  it  is  absolutely  hopeless. 

Treatment. — Up  to  the  present  time  no  treatment  is  known 
to  have  any  beneficial  effect  on  this  disease. 


TETANUS  645 

TETANUS 

Etiology. — ^Tetanus  is  an  acute  infection  caused  by  a  bacillus 
that  was  discovered  by  Nicolaier.  The  organism  enters  the 
body  through  a  wound  of  the  skin  or  the  mucous  membranes. 
It  is  generally  introduced  deeply  into  the  tissues,  and  grows 
enaerobically.  As  a  result  of  the  growth  of  this  organism  a 
toxemia  is  produced  which  causes  the  disease. 

The  spores  of  the  bacillus  may  retain  their  virulence  for  many 
years.  The  bacillus  or  its  spores  are  generally  introduced  into 
the  body  by  some  contaminating  object,  such  as  splinters,  nails,  ^ 
glass,  instruments,  and  the  like.  It  may  also  be  introduced  as 
the  result  of  administration  of  antitoxins,  injections  of  gelatin, 
powder  wounds,  etc. 

Tetanus  occurs  more  frequently  in  w^armer  climates,  owdng  to 
the  fact  that  in  these  climates  greater  portions  of  the  body  are 
exposed  because  unprotected  by  clothing. 

Pathology. — There  is  generally  evidence  of  some  local  wound 
or  abrasion,  w^hich  may  or  may  not  be  extensive.  As  the  result 
of  metabolic  changes  taking  place  during  the  growth  of  the 
tetanus  bacillus  introduced  in  the  w^ound  toxic  substances  are 
produced  that  at  first  cause  local  changes  in  the  ner\^es  adja- 
cent to  the  injured  parts.  These  are  followed  by  changes  in 
the  cells  in  the  anterior  horns  of  the  spinal  cord  and  gray  matter 
of  the  medulla. 

Symptoms. — ^The  first  symptoms  appear  at  variable  periods 
after  the  injury,  sometimes  in  three,  four,  or  five  days,  and  in 
some  cases  after  several  wrecks. 

Stiffness  and  contractions  of  the  muscles  of  the  face,  body, 
and  neck,  w^hich  may  be  most  mild  or  very  marked,  are  usually 
the  first  symptoms  to  appear.  Later  these  symptoms  become 
more  marked,  spasm,  and  finally  inability  to  open  the  mouth 
(trismus)  occur.  Soon  after  this  opisthotonos  occurs,  and  stiff- 
ness of  the  muscles  of  the  larynx  and  pharynx,  giving  rise  to 
difl&culty  in  sw^allowing.  The  stiffness  is  followed  by  spasmodic 
contraction  which  increases  from  day  to  day,  and  rapidly  spreads 
to  involve  the  muscles  of  the  trunk  and  extremities.  The 
spasms  spread  from  one  group  of  muscles  to  another,  following  a 


646  MANUAL   OF   NERVOUS   DISEASES 

descending  direction.  The  ocular  muscles  are  rarely  affected, 
and  finally  the  respiratory  muscles  become  involved,  and 
breathing  is  carried  on  only  with  difficulty.  The  muscle  con- 
tractions are  accompanied  by  cramp-like  pains. 

Clonic  spasmodic  contractions  occur  in  some  cases.  The 
intervals  between  the  spasmodic  attacks  may  be  long  or  short. 
During  these  attacks  the  pain  becomes  much  more  marked. 
These  attacks  usually  last  only  a  few  seconds,  and  are  gener- 
ally of  reflex  origin,  being  brought  on  by  sudden  noises,  touch- 
ing the  patient,  bright  lights,  odors,  etc.  Speech  and  deglu- 
tition are  generally  difficult  and  frequently  impossible.  The 
functions  of  the  bowels  and  bladder  may  be  impaired,  and 
often  there  is  retention  of  urine. 

Sensation  and  the  special  senses  are  hardly  ever  affected. 
Consciousness  is  not  affected  and  the  mind  generally  remains 
clear.  Profuse  perspiration  is  an  almost  constant  symptom.  The 
quantity  of  urine  excreted  is  usually  decreased.  The  tempera- 
ture is  generally  normal,  but  toward  the  end,  in  fatal  cases,  it 
rises  and  sometimes  becomes  very  high.  These  individuals 
present  a  very  characteristic  appearance,  generally  lying  in  bed, 
breathing  with  difficulty,  the  features  being  rigidly  contracted, 
the  forehead  furrowed,  the  eyelids  drawn  down,  the  mouth 
drawn  to  one  side  or  the  other,  the  jaws  tightly  closed,  and  the 
head  drawn  backward  or  to  the  side.  The  abdominal  muscles 
are  tense,  the  arms  and  the  legs  strongly  extended,  the  muscles 
standing  out  prominently,  and  the  facial  expression  showing 
that  the  patient  is  in  pain.  During  sleep  the  muscles  become 
relaxed. 

In  the  type  of  tetanus  known  as  head  tetanus,  or  the  hydro- 
phobic tetanus  of  Rose,  the  condition  is  due  to  an  infection  of 
the  face  or  skull  with  the  tetanus  bacillus.  The  symptoms  of 
this  type  of  infection  usually  occur  eight  or  nine  days  after  the 
infection  has  taken  place.  In  this  disease  the  first  symptom  to 
appear  is  spasm  of  the  facial  muscles  on  the  same  side  as  the 
injury;  this  is  later  followed  by  trismus,  which  is  unilateral  at 
first  and  later  becomes  bilateral.  The  muscular  contractions 
spread  to  the  pharynx  and  larynx  and  also  afi'ect  the  muscles 
of  the  neck.    In  a  short  time  the  facial  spasm  becomes  converted 


TETANUS  647 

into  a  facial  paralysis  which  is  either  partial  or  complete.  In 
a  few  cases  the  facial  paralysis  is  not  preceded  by  a  spasmodic 
condition.  In  some  cases  the  muscular  rigidity  may  extend 
still  further  and  involve  the  muscles  of  the  trunk  and  of  the 
extremities. 

Course. — The  onset  of  the  disease  may  be  gradual  and  slowly 
progressive,  or  it  may  occur  more  or  less  suddenly  and  be  rapidly 
progressive,  beginning  sometimes  with  evidences  of  local  ir- 
ritation in  the  region  of  the  wound. 

In  mild  cases  the  disease  is  limited  to  stiffness  and  contraction 
of  the  muscles  of  mastication  and  deglutition.  In  more  marked 
cases  the  symptoms  gradually  progress  until  the  muscles  of  the 
throat,  trunk,  and  extremities  are  involved.  Stiffness  and 
contraction  are  the  prominent  symptoms. 

In  the  severer  cases  the  progress  of  the  symptoms  is  rapid, 
and  in  addition  to  stiffness  and  contraction  spasmodic  attacks 
occur.    The  disease  lasts  from  a  few  days  to  several  weeks. 

Prognosis. — In  the  majority  of  cases  the  prognosis  is  un- 
favorable, death  usually  occurring  wdthin  five  or  six  days; 
it  may  not  occur,  however,  for  several  weeks,  death  being  gen- 
erally the  result  of  asphyxia  or  exhaustion.  In  head  tetanus 
death  usually  results  from  pneumonia,  erysipelas,  meningitis, 
exhaustion,  etc. 

The  longer  the  interval  between  the  infection  and  the  appear- 
ance of  the  tetanic  symptoms,  the  more  favorable  is  the  outlook. 
In  those  cases  in  which  the  disease  takes  a  favorable  course 
convulsive  seizures  and  spasms  finally  become  less  marked  and 
eventually  the  rigidity  disappears.  Trismus  is  the  last  symptom 
to  disappear.  Convalescence  is  usually  protracted.  If  the 
symptoms  are  mild  from  the  start  and  increase  slowly,  recovery 
may  be  expected.  In  those  cases  in  which  the  first  s\Tnptoms 
appear  within  five  days  after  the  injury  and  in  puerperal  tetanus 
the  prognosis  is  generally  very  grave.  In  head  tetanus  the 
prognosis  is  usually  more  favorable  than  in  general  tetanus. 

Diagnosis. — This  disease  must  be  differentiated  from  str^'ch- 
nin-poisoning,  from  hydrophobia,  and  from  hysteric  conditions. 
The  differentiation  from  strychnin-poisoning  is  generally  made 
from  the  history  of  the  case  and  from  the  fact  that  generalized 


648  MANUAL   OF   NERVOUS   DISEASES 

convulsions  are  marked,  whereas  in  tetanus  the  muscular 
contractions  progress  much  more  slowly,  and  the  reflex  con- 
vulsions are  usually  not  so  well  marked.  In  tetanus  the  trismus 
is  an  early  and  prominent  symptom;  in  strychnin-poisoning  it 
is  no  more  marked  than  any  of  the  other  muscle  symptoms. 

From  hydrophohia  the  condition  is  differentiated  from  the 
history,  the  presence  of  permanent  muscular  rigidity,  and  the 
involvement  of  the  jaw  muscles  first;  whereas  in  hydrophobia 
the  rigidity  is  not  permanent,  and  the  throat  muscles  are  the 
first  to  be  involved.  From  hysteria  the  differentiation  is  usually 
made  with  very  little  difficulty,  as  in  this  condition  there  is  an 
absence  of  trismus  and  of  permanent  muscular  rigidity,  and  the 
spasms,  when  they  occur,  are  commonly  purposive  in  character, 
and  not  indicative  of  a  reflex  origin. 

Treatment. — The  patient  should  be  placed  in  a  darkened, 
quiet  room,  and  should  be  protected  from  all  noise  and  excite- 
ment. He  should  be  handled  as  little  as  possible,  and  every 
form  of  external  irritation  should  be  eliminated.  He  should  be 
given  an  abundance  of  fluids  and  as  nourishing  a  diet  as  possible; 
if  necessary,  the  food  may  be  given  through  a  tube  passed  between 
the  teeth  or  through  the  nose;  in  addition  to  this,  nutritive 
enemata  may  be  given. 

The  localized  point  of  infection  should  be  thoroughly  cleansed 
and  the  wound  enlarged  and  disinfected.  Antitetanic  serum 
should  be  freely  injected  into  and  about  the  seat  of  injury,  and 
should  also  be  given  subcutaneously  and  intraspinously.  In 
order  that  the  serum  may  be  effective  it  should  be  given  early 
and  in  very  large  quantities.  In  order  to  prevent  the  develop- 
ment of  tetanus  it  is  most  important  that  all  wounds  should 
receive  proper  surgical  treatment,  and  those  that  are  the  result 
of  punctures,  occurring  particularly  on  exposed  surfaces  of  the 
body  or  in  the  presence  of  dirt,  should,  in  addition  to  being 
treated  surgically,  have  injected  around  and  into  them  a  moder- 
ately large  amount  of  antitetanic  serum. 

Owing  to  the  fact  that  the  treatment  of  this  condition  with 
serum  does  not  always  result  favorably,  and  also  because  of  the 
fact  that  these  patients  generally  suffer  considerable  discomfort, 
it  is  necessary,  in  addition  to  the  administration  of  the  serum,  to 


TETANUS  649 

resort  to  other  therapeutic  measures.  Chloral  hydrate,  given  in 
doses  of  from  20  to  40  grains  four,  five,  or  six  times  a  day,  alone 
or  combined  with  morphin,  is  one  of  the  best  remedies  for 
relieving  the  muscle  contractions.  The  patient  should,  so  far 
as  possible,  be  kept  in  a  state  of  narcosis.  Chloroform  may 
also  be  used,  especially  to  control  the  convulsions,  and  the 
bromids  in  large  doses  should  always  be  given.  The  sub- 
cutaneous injection  of  about  30  minims  of  a  2  per  cent,  solution 
of  phenol  every  tw^o  hours  has  also  been  recommended,  and 
seems  to  be  very  effective  in  the  treatment  of  this  condition. 
Continuous  warm  baths  may  also  be  useful  in  relieving  the 
muscle  spasms.  When  the  symptoms  become  less  intense,  it 
is  very  important  that  the  patient's  strength  be  sustained  by  a 
nourishing  diet  and  an  abundance  of  fluids.  Care  must  be 
exercised  to  prevent  the  entrance  of  fluids  or  foods  into  the 
lungs.  The  condition  of  the  bowels  and  bladder  should  also 
be  carefully  supervised. 


INDEX 


Abdominal  neuralgia,  234 

reflex,  158 
Abducens  nerve,  129 

examination  of,  173 
Abscess  of  brain,  426 
Accommodation,  reaction  to,  173 
Achondroplasia,  641 
Acromegaly,  605 
Acroparesthesia,  184,  618 
Acute  ascending  paralysis,  356 

circumscribed  edema,  635 
Agoraphobia,  513 
Ala  cinerea,  63 

Alcohol,  multiple  neuritis  due  to,  213 
Amaurotic  family  idiocy,  418    »^«- 
Amyotrophic  lateral  sclerosis,  295  ' 
Anemia,  cerebral,  380 
Angioneurotic  edema,  635 
Anterior  poliomyelitis,  acute,  278 
chronic,  286 
subacute,  286 
Anterolateral  ground  bundle,  func- 
tion of,  55 
Anxiety  neurosis,  517 
Apoplexy,  391 
Apraxia,  165 

Aqueduct  of  Sylvius,  62,  64 
Arachnoid,  32 

pia,  21 
Aran-Duchenne  type  of  progressive 

atrophy,  286 
Argyll  Robertson's  sign,  308 
Arsenic,  multiple  neuritis  due  to,  216 
Arterial  system,  central,  114 
Arteries,  posterior  cerebral,  109 
communicating,  in 
inferior  cerebellar,  109 
internal  carotid.  109 

root,  anterior,  50 
posterior,  50 

vertebral,  109 


Artery,  anterior  cerebral,  no 
choroid,  113 
communicating,  no 
inferior  cerebellar,  109 
basilar,  109 
middle  cerebral,  in 
of  cerebral  hemorrhage,  in 
spinal  anterior,  50 
Ataxia,  313,  441 
hereditary,  298 
locomotor,  303 

Marie's  cerebellar  hereditary,  302 
static,  299 
Ataxic  paraplegia,  269 
Athetoid  movements,  149 
i\trophic  spinal  paralysis,  278 
Atrophy,  optic,  254 

progressive,  Aran-Duchenne  type. 
286 
spinal  muscular,  286 
Auditory  ner\'e,  132 
disorders  of,  263 
Axon,  25 


Babixski  reflex,  158 
Basedow's  disease,  575 
Basifar  ganglia,  no,  117 
Basis  pedunculi,  65 
Bell's  paralysis,  259 
Benedikt's  syndrome,  269,  445 
Bergeron's  chorea,  544 
Bergmann,  197 
Beriberi,  220 
Bernhard's  disease,  201 
Betz,  cells  of,  90 
*Biceps  reflex,  154 
Birth  palsy  of  Duchenne,  194 
Blepharoclonus,  524 
Blepharospasm,  524 
Blindness,  hysteric,  481 


651 


652 


INDEX 


Bonnet's  sign,  236 
Brachial  neuralgia,  233 

neuritis,  194 

plexus,  disease  of,  180 
Brain  abscess,  426 

lesions,  organic,  with  chorea,  547 

tumor,  440 
Breast,  neuralgia  of,  234 
Brissaud,  526 
Broca's  convolution,  85 
Brown-Sequard  syndrome,  334,  335 
Bulbar  paralysis,  progressive,  274 
Burdach,  column  of,  48 


Caisson  disease,  469 
Calcarine  fissure,  88 
Caloric  reaction,  175 
Capsule,  external,  108 

internal,  functions  of,  106 
Caries,  spinal,  319 
Catalepsy,  414 
Cauda  equina,  32 
Cells,  functions  of,  27 

of  Betz,  90 

of  Purkinje,  79 
Central  canal,  42 
Cerebellar  incision,  anterior,  74 

tract,  direct,  55 
Cerebellum,  73 

functions  of,  81 

microscopic  structure  of,  79 

peduncles  of,  75 

structure  of,  79 
Cerebral  anemia,  380 

arteries,  occlusion  of,  383 
rupture  of,  383 

cortex,  functions  of,  116 

hyperemia,  382 

peduncles,  64,  90 

sinuses,  thrombosis  of,  403 

tumors,  433 

vein,  internal,  99 
Cerebrospinal  fluid,  22,  146 
in  tabes,  316 

meningitis,  epidemic,  368 
Cerebrum,  81 

Cervicobrachial  neuritis,  186 
Cervico-occipital  neuralgia,  233 
Charcot's  disease,  220 

joints,  316 
Chiasm,  optic,  92 


Chippault's  rule,  40,  338 
Choked  disk,  252 
Chorda  tympani,  131 
Chorea  accompanying  organic  brain 
lesions,  547 

Bergeron's,  544 

chronic  progressive,  543 
hereditary,  543 

congenital,  547 

Dubini's,  549 

electric,  549  .    x 

epidemic,  548 

Henoch's,  550 

Huntington's,  543 

insaniens,  534 

minor,  Sydenham's,  533 

paralytic,  538 
Choreiform  movements,  149 
Chvostek's  sign,  591 
Circle  of  Willis,  90,  113 
Circumflex  nerves,  paralysis  of,  197 
Claustrophobia,  513 
Coal-tar  products,  neuritis  due  to, 

219 
Cochlear  nerve,  133 
Colitis,  mucous,  504 
Column,  anterior,  45 

Burdach's,  48 

Coil's,  48 

lateral,  45 

posterior,  45 
Commissure,  anterior,  104 

gray,  104 

posterior,  42,  105 

white,  42 
posterior,  43 
Congenital  spinal  malformation,  357 
Conjunctival  reflex,  160 
Convolution,  Broca's,  85 

occipitotemporal  superior,  88 

paracentral,  88 
Convulsions,  149 
Corneal  reflex,  160 
Corpora  quadrigemina,  65 
functions  of,  71 

striata,  100 
Corpus  callosum,  102 
Corrugator  supercilii  reflex,  156 
Cortex,  cerebral,  functions  of,  116 
Cranial  nerves,  anatomy,  123 
diseases  of,  250 
physiology,  123 


INDEX 


653 


Cremasteric  reflex,  158 
Cretinism,  583 
Crises,  gastric,  305 

intestinal,  307 

laryngeal,  307 

pharyngeal,  307 

rectal,  307 
Crura,  disease  of,  269 

functions  of,  71 
Crural  neuralgia,  234 
Crusta,  70 
Cuneus,  88 


Deep  sensibility,  55,  163 
Degeneration,  process  of,  181 

reaction  of,  170,  183 

Wallerian  law  of,  27 
Dementia,  paralytic,  449 
Dendrons,  24 
Dentate  fascia,  33 
Diadokokinesis,  151 
Dipsomania,  515 
Direct  cerebellar  tract,  function  of, 

55 
Disk,  choked,  252 
Dislocation  of  spinal  column,  325 
Disseminated  sclerosis,  465 
Double  personality,  476 
Dubini's  chorea,  549 
Duchenne,  birth  palsy  of,  194 

pseudomuscular    hypertrophy    of, 
240 

subacute  ascending  paralysis,  286 
Duchenne-Landouzy-Dejerine     type 

of  dystroph}^,  240 
Dura  mater,  19 
Dysbasia  lordotica,  530 
Dystrophy,  Duchenne-Landouzy-De- 
jerine type,  240 

Erb's  juvenile,  240 

progressive  muscular,  239 


Edema,  acute  circumscribed,  635 

angioneurotic,  635 
Electric  chorea,  549 

examination,  167 
Encephalitis,  acute  non-suppurative 

hemorrhagic,  408 
Endoneurium,  31 
Epicritic  sensibility,  55,  162 


Epidemic  chorea,  548 
Epilepsy,  557 
Jacksonian,  558 
myoclonus,  of  Unverricht,  572 
nocturnal,  558 
psychic,  557 
Epineurium,  31 
Ecjuilibrium,  123 

Erb's  combined  shoulder-arm  paral- 
ysis, 190 
juvenile  dystrophy,  240 
sign,  592 
Erythromelalgia,  627 
Examination,  electric,  167 
nerv^e,  abducens,  173 
facial,  174 

glossopharyngeal,  175 
hypoglossal,  176 
motor  oculi,  173 
optic,  172 
patheticus,  173 
pneumogastric,  175 
spinal  accessory,  175 
trifacial,  174 
of  nervous  system,  147 
of  patient,  142 
physical,  145 
Exhaustion,  nervous,  493 
Exophthalmic  goiter,  575 
Exophthalmos,  577 
External  cutaneous  nerve,  neuritis  of, 
201 
popliteal  nerve,  neuritis  of,  204 

Facial    hemiatrophy,     progressive, 

637 

nen-'e,  diseases  of,  259 
examination  of,  174 

spasm,  522 

tic,  524 
Falling  sickness,  557 
Family  idiocy,  amaurotic,  418 
Fasciae  dentatae,  33 
Fasciculus  cimieatus,  61 

gracilis,  61 

of  Rolando,  61 
Fever,  hysteric,  483 
Fibers,  external  arcuate,  60 

of  Remak,  27 
Fifth  nerve  disease^  258 
Fillet,  69 


654 


INDEX 


Fissure,  anterior  median,  35 

anterolateral,  58 

calcarine,  88 

callosomarginal,  87 

corpus  callosum,  87 

dentate,  88 

hippocampal,  88 

of  Rolando,  82 

of  Sylvius,  82 

parieto-occipital,  82,  88 

posterior  median,  35 

subparietalis,  87 
Focal  symptoms,  440 
Foerster's  method,  421 

operation,  317 
Folie  du  doute,  514 
Foot-drop,  213 
Foramen  of  Magendie,  35,  60 

of  Monro,  96 

of  Retzius,  35,  60 
Forma tio  reticularis,  67 
Fornix,  105 

Fourth  nerve,  paralysis  of,  256 
Fracture  of  spinal  column,  325 
Frenkel's  operation,  317 
Frohlich's  syndrome,  599 


Gait,  scissors,  418 

steppage,  215,  220 
Galvanic  current,  169 
Ganglia,  basal,  100,  117 
Ganglion,  geniculate,  131 
Ganglionic  system,  central,  114 
Gangrene,  symmetric,  629 
General  paralysis  of  insane,  449 

paresis,  449 
Geniculate  body,  external,  66 

internal,  66 
ganglion,  131 
Gersuny's  paraffin  injection,  639 
Gigantism,  603 
Gliosis,  spinal,  292 
Globus  hystericus,  474 
Glossolabiopharyngeal  paralysis, 
Glossopharyngeal  nerve,  133 

disease  of,  264 

examination  of,  175 
Goiter,  exophthalmic,  575 
Goll,  column  of,  48 

functions  of,  55 
Grand  mal,  557,  561 


274 


Graves'  disease,  575 
Groove,  posterolateral,  59 
Ground-bundle,  anterolateral,  46,  48 
function  of,  55 


Habit  spasms,  530 
Hand,  trident,  640 
Hematomyelacia,  349 
Hemianopsia,  unilateral  nasal,  251 
Hemiatrophy,  progressive  facial,  637 
Hemicrania,  620 
Hemiplegia,  393 
Hemorrhage,  cerebral,  artery  of,  iii 

meningeal,  361 
Henoch's  chorea,  550 
Hereditary  ataxia,  298 

syphilis,  461 
Herpes  zoster,  222 
Hippocampus  major,  96 
Hoffman's  sign,  591 
Horn,  lateral,  42 

posterior,  42 
Huntington's  chorea,  543 
Hydrocephalus,  422 
Hydrophobia,  647 
Hyperemia,  cerebral,  382 
Hypertrophic  pachymeningitis,  341 
Hypertrophy,     pseudomuscular,     of 

Duchenne,  240 
Hypoglossal  nerve,  58,  136 

examination  of,  175 
Hypophysis  cerebri,  92 

functions  of,  117,  598 
Hypotonia,  309 
Hysteria,  471 

major,  474 

minor,  474 
Hysteric  fever,  483 

ptosis,  481 

vomiting,  483 
Hysterogenic  zones,  165,  480 


Idiocy,  amaurotic  family,  418 
Illuminating   gas,    multiple   neuritis 

due  to,  219 
Imperative  idea,  513 
Infantile  spinal  paralysis,  287 
Infantilism,  611 

cachectic  type,  612 

ductless  gland,  613 


INDEX 


655 


Infantilism,  Lorain  type,  611 
Insane,  general  paralysis  of,  449 
Intention  tremor,  466 
Intercostal  nerves,  paralysis  of,  200 

neuralgia,  233 
Internal  popliteal  nerve,  neuritis  of, 

204 
Interstitial  neuritis,  181 
Ischemic  paralysis,  246 
Island  of  Reil,  84 
Isthmus,  88 


Jacksonian  epilepsy,  558 
Jaw  reflex,  155 
Jonnesco's  operation,  583 


Kleptomania,  515 
Klumpke's  paralysis,  191 
Knee  reflex,  153 
Korsakoff's  syndrome,  214 


Lancisi,  ner\'es  of,  103 
Landry's  paralysis,  356 
Lateral  sclerosis,  295 
Lead-poisoning,  multiple  neuritis  due 

to,  219 
Lemniscus,  69 
Leprous  neuritis,  222 
Light  sensibility,  162 
Lissauer's  marginal  tract,  46,  48 
Little's  disease,  417 
Lobe,  central,  84,  87 

frontal,  84 

limbic,  84,  88 

occipital,  85 

olfactory,  84,  85 

parietal,  85 

temporal,  86 
Lobule,  quadrate,  88 
Locomotor  ataxia,  303 
Locus  coeruleus,  62 
Lorain  type  of  infantilism,  611 
Lumbar  neuralgia,  234 

plexus,  disease  of,  201 


Magexdie,  foramen  of,  35,  60 
Marie's  cerebellar  hereditary  ataxia, 
302 


Martin's  sign,  236 

Mastication,  spasm  of  muscles  of,  526 

Mastodynia,  234 
Medulla,  disease  of,  269 
function  of,  71 
structure  of,  66 
Medullary  velum,  anterior,  62 

superior,  77 
Meningeal  hemorrhage,  361 
Meningismus,  378 
^Meningitis,  364 
chronic,  343 

epidemic  cerebrospinal,  368 
secondary,  365 
septic,  365 
serous,  378 
spinal,  339 
syphiUtic,  375 
tubercular,  372 
Meralgia  paraesthetica,  201 
Migraine,  620 
Mobius'  sign,  579 
Monro,  foramen  of,  96 
Morton's  toe,  205 
Motor  impulse,  course  of,  117 
ner\^_e,  30,  31 
oculi  ner\"e,  173 
system,  examination  of,  148 
Movements,  athetoid,  149 

choreiform,  149 
Mucous  colitis,  504 
Multiple  neuritis,  206 
course,  210 
diagnosis,  211 
due  to  alcohol,  213 
to  arsenic,  216 
to  coal-tar  products,  219 
to  illimiinating  gas,  219 
to  lead-poisoning,  219 
etiology,  207 
prognosis,  210 
symptoms,  207 
treatment,  210 
sclerosis,  465 
Muscle  sense,  56 

spasms,  localized,  522 
Muscular  dystrophy,  progressive,  239 

system,  disease  of,  239 
Musculospiral  nerve,  paral3'sis  of,  197 
Myasthenia  gravis,  277,  594 
Myasthenic  reaction,  170,  595 
Myatonia  congenita,  247 


656 


INDEX 


Myelitis,  344 

Myoclonus   epilepsy  of  Unverricht, 
572 
multiplex,  573 
Myotonia  congenita,  247 
Myotonic  reaction,  170 
Mysophobia,  513 
Myxedema,  583 


Nerve,  abducens,  129 

examination  of,  173 
auditory,  132 
circumflex,  paralysis,  197 
cochlear,  133 
facial,  130 

diseases  of,  259 

examination  of,  174 
fifth,  disease  of,  258 
fourth,  paralysis  of,  256 
glossopharyngeal,  133 

disease  of,  264 
hypoglossal,  58,  136 
motor,  30,3 1 

musculospiral,  paralysis  of,  197 
obturator,  disease  of,  201 
oculomotor,  125 
olfactory,  123 
optic,  125 

disorders  of,  251 

examination  of,  172 
phrenic,  paralysis  of,  186 
pneumogastric,  61,  135 
sciatic,  203 
sensory,  30,  31 
sixth,  paralysis  of,  256 
spinal  accessory,  61,  127 
suprascapular,  paralysis  of,  197 
trifacial,  127 
tumors  of,  225 
ulnar,  paralysis  of,  199 
Nerve-fiber,  medullated,  27 
non-medullated,  27 
structure  of,  36 
Nerve-root,  anterior,  37 

posterior,  37 
Nerves,  cranial,  123 
diseases  of,  250 
of  Lancisi,  103 
Nervous  exhaustion,  493 
system,  examination  of,  147 

sympathetic,  136 


Nervous  system,  sympathetic,  func- 
tions of,  139 
syphilis  of,  459 
Neuralgia,  226 

abdominal,  234 

brachial,  233 

cervico-occipital,  233 

course,  228 

crural,  234 

diagnosis,  228 

etiology,  227 

intercostal,  233 

lumbar,  234 

of  breast,  234 

pathology,  226 

prognosis,  228 

sciatic,  235 

symptoms,  227 

treatment,  229 

trigeminal,  230 
Neurasthenia,  493 
Neuritis,  brachial,  194 

cervicobrachial,  186 

course,  185 

etiology,  182 

external  cutaneous,  201 

internal  popliteal,  204 

interstitial,  181 

leprous,  222 

multiple,  206.      See  also  Multiple 
neuritis. 

of  sacral  plexus,  201 

optic,  253 

parenchymatous,  181 

plantar,  205 

popliteal,  external,  204 

postdiphtheritic,  219 

prognosis,  175 

puerperal,  220 

symptoms,  182 

treatment,  186 
Neurogliar  tissue,  42,  513 
Neuron,  23 
Neurosis,  anxiety,  517 

occupation,  518 
Nocturnal  epilepsy,  558 
Node  of  Ranvier,  26 
Nucleus  cuneatus,  62 

gracilis,  62 

red,  70 

trigeminal,  62 
Nyctophobia,  513 


INDEX 


657 


Obsessions,  intellectual,  514 

volitional,  514 
Obstetric  paralysis  (mother),  194,  202 
Obturator  nerv-e,  disease  of,  201 
Occipital  sinus,  20 
Occupation  neurosis,  518 

pareses,  206 

spasms,  518 
Oculomotor  ner\'e,  125 
Olfactory  nerve,  1 2;^ 

disease  of,  250 
Olives,  59 
Ophthalmoplegia,  257 

external,  257 

internal,  257 
Oppenheim's  disease,  247 
Optic  atrophy,  254 

chiasm,  92 

ner\'e,  125 

disorders  of,  251 
examination  of,  172 

neuritis,  253 

tracts,  92 


Pachymexixgitis,  external,  355 

hypertrophic,  341 

internal,  359 
Pain,  162 

sense,  121 
Palsy,  shaking,  550 
Paraesthesia,  163 

Parafi&n  injection,  Gersuny's,  639 
Paralysis,  acute  ascending,  356 

agitans,  550 

atrophic  spinal,  278 

Bell's,  259 

Erb's  combined  shoulder-ann,  190 

general,  of  insane,  449 

glossolabiophar\^ngeal,  274 

infantile  spinal,  287 

ischemic,  246 

Klumpke's,  191 

Landry's,  356 

obstetric,  194,  202 

of  circumflex,  neiA-es,  197 

of  intercostal  nerves,  200 

of  musculospiral  ner\'e,  197 

of  phrenic  ner\-e,  186 

periodic,  249 

progressive  bulbar,  274 

sixth  nerve,  256 

42 


Paralysis,    subacute    ascending,    of 
Duchenne,  286 

ulnar  nerve,  199 

V'olkmann's,  246 
Paralytic  chorea,  538 

dementia,  449 
Paramyoclonus  multiplex,  573 
Paraplegia,  ataxic,  269 

senile,  355 
Parathyroid  glands,  590 
Parenchymatous  neuritis,  181 
Paresis,  general,  449 

occupation,  206 
Peduncles,  cerebral,  64,  90 

cerebelli  inferior,  77 
middle,  77 
superior,  76   • 
Perineum,  31 
Periodic  paralysis,  249 
Periosteoradial  reflex,  154  ' 
Personality,  double,  476 
Petit  mal,  557,  562 
Pharyngeal  reflex,  160 
Phrenic  ner\-e,  paralysis  of,  186 
Physical  examination,  145 
Pineal  gland,  102 

disorders  of,  615 
Pituitar}^  body,  92 
disorders  of,  597 
function  of,  117,  598 
symptoms  due  to  disturbance  of 
secretion,  599 
Plantar  ner\-e3,  neuritis  of,  205 
Plexus,  arterial,  anterior,  50 
Pneumogastric  nerve,  61,  135 

examination  of,  175 
Points  of  Valleix,  235 
Poliomyelitis,  acute  anterior,  278 

chronic,  286 

subacute.  286 
Pol}Tnyositis,  244  • 
Pons,  functions  of,  71 

structure  of,  66 

varolii,  62 
Postdiphtheritic  neuritis,  219 
Postepileptic  mental  states,  564 
Posterior  inferior  cerebral  artery,  oc- 
clusion of,  270 

perforated  space,  92 
Prsecimeus,  88 
Progressive  spinal  muscular  atrophy, 

286 


658 


INDEX 


Projection  tract,  115 
Protopathic  sensibility,  163 
Pseudomuscular  hypertrophy  of  Du- 

chenne,  240 
Pseudotabes  alcoholica,  215 
Psychalgia,  228 
Psychic  epilepsy,  557 
Ptosis,  hysteric,  481 
Puerperal  neuritis,  220 
Puncture,  spinal,  176 
Purkinje,  cells  of,  79 
Putamen,  loi 

Pyramidal  tract,  crossed,  46,  47 
direct,  46,  47 


Quadrate  lobule, 


Ran\^ieb,  node  of,  26 
Raynaud's  disease,  629 
Reaction,  caloric,  175 

myasthenic,  170,  595 

myotonic,  170 

of  degeneration,  170,  183 

tetanic,  170 

to  accommodation,  173 
Recklinghausen's  disease,  225 
Rectal  reflex,  161 
Reflex,  abdominal,  158 

Babinski,  158 

biceps,  154 

conjunctival,  160 

corneal,  160 

corrugator  supercilii,  156 

cremasteric,  158 

jaw,  J 55 

knee,  153 

periosteo  radial,  154 

pharyngeal,  160 

rectal,  161 

superficial,  157 

tendo  Achillis,  152 

triceps,  155 

vesical,  161 
Reflexes,  152 
Regeneration,  28 
Reid's  line,  179 
Reil,  island  of,  84 
Remak,  fibers  of,  27 
Rest-cure,  Weir-Mitchell's,  510 
Retzius,  foramina  of,  35,  60 


Rolando,  fasciculus  of,  61 

fissure  of,  82 
Romberg's  sign,  150,  309 
Roots,  anterior,  43 

posterior,  43 
Rubrospinal  tract,  71 
Rump's  sign,  501 


Sacral  plexus,  neuritis  of,  201 
Schwann,  sheath  of,  26 
Sciatic  nerve,  203 

neuralgia,  235 
Sciatica,  235 
Scissors  gait,  418 
Scleroderma,  639 

Sclerosis,  amyotrophic  lateral,    295, 
298  _ 

disseminated,  465 

multiple,  465 
Secretory  disturbance,  165 
Senile  paraplegia,  355 
Sensation,  55 

deep,  55,  163 
Sense,  muscle,  56 

pain,  121 

stereognostic,  165 
Sensibility,  protopathic,  163 
Sensory  function,  162 

impulse,  course  of,  117 

nerve,  30,  31 
Shaking  palsy,  550 
Sheath  of  Schwann,  26 
Sign,  Bonnet's,  236 

Chvostek's,  591 

Erb's,  592 

Hoffman's,  591 

Martin's,  236 

Mobius,  579 

Romberg's,  150,  309 

Rump's,  501 

Stellwag's,  579 

von  Graefe's,  579 

Westphal's,  308 
Sinus,  longitudinal,  20 

occipital,  20 

straight,  20 
Sinuses,  lateral,  20 
Sixth  nerve  paralysis,  256 
Somnambulistic  attacks,  476 
Space,  subarachnoid,  21,  33 
Spasm,  149 


INDEX 


659 


Spasm,  facial,  522 
Spasmodic  torticollis,  526 
Spasms,  habit,  530 

localized  muscle,  522 

occupation,  518 

of  muscles  of  mastication,  526 
Spina  bifida,  357 
Spinal  accessory  nerve,  61,  127 
disease  of,  267 
examination  of,  175 

canal,    syphilitic    exudation    into, 

325 
caries,  319 
column,   fracture   and   dislocation 

of,  325 
cord,  anatomy  of,  32 
blood  supply  of,  50 
cellular  constituents  of,  53 
physiology  of,  32,  53 
pressure  on,  319 
segment  of,  38 
functions,  57 
structure  of,  40 
tumors  of,  331 
gliosis,  292 

malformation,  congenital,  357 
meningitis,  339 
puncture,  176 
Spinothalamic  tract,  69 
Static  ataxia,  299 
Status  epilepticus,  563 
S  tell  wag's  sign,  579 
Steppage  gait,  215,  220 
Stereognostic  sense,  165 
St.  Vitus'  dance,  533 
Subarachnoid  space,  21,  33 
Substantia  nigra,  70 
Suprascapular    nerve,    paralysis    of, 

197 
Sydenham's  chorea,  533 
Sylvius,  aqueduct  of,  fe,  64 

fissure  of,  82 
Symmetric  gangrene,  629 
Sympathetic  nervous  system,  136 

functions  of,  136 
Syndrome,  Benedikt's,  269,  445 
Brown-Sequard's,  334 
Frohlich's,  599 
Korsakoff's,  214 
Weber's,  269 
Syphilis,  hereditary,  461 
of  nervous  system,  459 


Syphilitic  exudation  into  spinal  canal, 

3.25 
Syringomyelia,  292 


Tabes  dorsalis,  303 

cerebrospinal  fluid  in,  316 
Tabetic  arthropathies,  311 
Tachycardia,  576 
Tactile  sense,  121,  162 
Tangential  tract,  114 
Tegmentum,  65,  70 
Tela  choroidea,  inferior,  60 
Temperature  sense,  121,  162 
Tenderness  of  nerve-trunks  on  press- 
ure, 163 
Tendo  Achillis  reflex,  152 
Tentorium  cerebelli,  73 
Tetanic  reaction,  170 
Tetanus,  644 

head  type,  645 

hydrophobic,  645 
Tetany,  589 
Thomsen's  disease,  247 
.Thrombosis,  infective,  405 

of  cerebral  sinuses,  403 

of  lateral  sinus,  406 

of  longitudinal  sinus,  405 
Tic,  530 

douloureux,  231 

facial,  524 
Tinnitus  aurium,  264 
Toe,  Morton's,  205 
Torticollis,  spasmodic,  526 
Tortipelvis,  530 
Tract,  anterolateral,  69 

cerebellar  direct,  46,  47 

comma,  46 

comma-shaped,  Schultze's,  50 

commissural,  114 

Gower's,  46,  47 

marginal,  Lissauer's,  46,  48 

of  cord,  functions  of,  54 

optic,  92 

projection,  115 

pyramidal,  crossed,  46,  47 
direct,  46,  47 

rubrospinal,  71 

spinothalamic,  69 

tangential,  114 

ventrospinocerebellar,  69 
Tremor,  intention,  466 


66o 


INDEX 


Tremors,  148,  557 
Triceps  reflex,  155 
Trident  hand,  641 
Trifacial  nerve,  127 

examination  of,  174 
Trigeminal  neuralgia,  230 
Trigonum  hypoglossi,  62 
Trophic  disturbances,  166 
Trophoneuroses,  637 
Tuber  cinereum,  92 
Tumors,  cerebral,  433 

nerve,  127 

of  spinal  cord,  331 


Ulnar  nerve,  paralysis  of,  199 
Unverricht,  myoclonus  epilepsy  of, 
572 


Valleix,  points  of,  235 
Valve  of  Vieussens,  64,  77 
Vasomotor  disturbances,  165 


Velum,  medullary,  anterior,  62 

superior,  77 
Ventricle,  fourth,  60,  62 

third,  96 
Ventricles,  lateral,  93 
Ventrospinocerebellar  tract,  69 
Vertebrae,  malignant  growths  of,  323 
Vertebral  arteries,  109 
Vesical  reflex,  161 
Vieussens,  valve  of,  64,  77 
Volkmann's  paralysis,  246 
Vomiting,  hysteric,  483 
Von  Graefe's  sign,  579 

Wallertan  law  of  degeneration,  27 
Weber's  syndrome,  269 
Weir-Mitchell's  rest  cure,  510 
Westphal's  sign,  308 
Willis,  circle  of,  90,  113 
Wrist-drop,  213 

Zones,  hysterogenic,  165,  480 


SAUNDERS'   BOOKS 


Practice,  Pharmacy, 
Materia  Medica,  Thera- 
peutics, Pharmacology, 
and  the  Allied  Sciences 

W.  B.  SAUNDERS  COMPANY 

West  Washington  Square  Philadelphia 

9,  Henrietta  Street  Covent  Garden,  London 

Our  Handsome  Complete  Catalogue  will  be  Sent  You  on  Request 

Medic&l  Clinics  of   Chicago 

Issued  serially,  one  octavo  of  200  pages,  illustrated,   every  other 
month.  Per  Clinic  Year  (July  to  May),  six  numbers:   Cloth,  $12.00  net. 

EXCLUSIVELY  INTERNAL  MEDICINE 

These  bi-monthly  publications  are  devoted  exclusively  to  Clinical  Internal 
Medicine  in  all  its  departments.  They  give  you  the  bedside  and  amphitheater 
teachings  of  leading  Chicago  internists,  representing  such  large  hosjiitals  as 
Mercy,  Cook  County,  St.  Luke's,  Michael  Reese,  and  Sarah  Morris  Memorial. 
The  widest  variety  of  cases  is  included,  bringing  out  forcibly  every  feature  of 
history-taking,  diagnosis,  treatment,  and  general  management.  The  cases 
are  illustrated  with  x-ray  pictures,  photographs,  pulse-tracings,  and  temper- 
ature charts ;  the  technic  of  all  laboratory  tests  is  given  in  detail,  and  every 
aid  that  can  serve  to  make  the  diagnosis  and  treatment  of  the  cases  thoroughly 
clear  to  the  general  practitioner  is  emphasized.  These  publications  are  clin- 
ical in  the  stj'ictest  sense — they  are  an  exposition  of  diagnosis  and  treatment  as 
actually  practiced  at  the  bedside  and  in  the  amphitheater. 


SAUNDERS'    BOOKS   ON 


Muster    and    Kelly    on 
Treatment 


A  Handbook  of  Practical  Treatment.  By  82  eminent 
specialists.  Edited  by  John  H.  Musser,  M.  D.,  and  A.  O.  J. 
Kelly,  M.  D.,  University  of  Pennsylvania.  Three  octavo  vol- 
umes, averaging  950  pages  each,  illustrated.  Per  volume  :  Cloth, 
^6.00  net;     Half  Morocco,  ^7.50  net. 

THE  TREATMENT  THAT  IS  ALL  TREATMENT 

Every  chapter  in  this  work  was  written  by  a  specialist  of  unquestioned 
authority.  Not  only  is  drug  therapy  given,  but  also  dietotherapy,  serumtherapy, 
organotherapy,  rest-cure,  exercise  and  massage,  hydrotherapy,  climatology, 
electrotherapy,  x-xa.y,  and  radial  activity  are  fully,  clearly,  and  definitely 
discussed.  Those  measures  partaking  of  a  surgical  nature  have  been  pre- 
sented by  surgeons. 

The  Medical  Record 

"  The  most  modern  and  advanced  views  are  presented.  It  is  difficult  to  pick  out  any 
one  topic  that  deserves  special  commendation,  all  parts  fully  covering  their  particular  field, 
and  written  with  that  fulness  of  detail  demanded  by  the  every-day  needs  of  the  practitioner." 


Thomson's  Clinical  Medicine 

Clinical  Medicine.  By  William  Hanna  Thomson,  M.D., 
LL.  D.,  formerly  Professor  of  the  Practice  of  Medicine  and  of 
Diseases  of  the  Nervous  System,  New  York  University  Medical 
College.  Octavo  of  667  pages.  Cloth,  ^5.00  net;  Half  Moroc- 
co, $6.50  net. 

A  RECORD  OF  50  YEARS 

This  new  work  represents  over  a  half  century  of  active  practice  and  teach- 
ing. It  deals  with  bedside  medicine— the  application  of  medical  knowledge 
for  the  relief  of  the  sick.  First  the  meaning  of  common  and  important  symp- 
toms is  stated  definitely ;  then  follows  a  chapter  on  the  use  of  remedies  and 
a  classification  of  them  ;  next  the  section  on  infections,  and  last  a  section  on 
diseases  of  particular  organs  and  tissues.  An  important  chapter  is  that  on  the 
mechanism  of  surface  chill  and  ''catching  cold,"  going  very  clearly  into  the 
etiologic  factors,  and  outlining  the  treatment.  The  chapter  on  remedies  takes 
up  non-medicinal  and  medicinal  remedies  and  vaccine  and  serum  therapy. 
The  infectious  diseases  are  taken  up  in  Part  II,  while  Part  III  deals  with 
diseases  of  special  organs  or  tissues,  every  disease  being  fully  presented  from 
the  clinical  side. 


PRACTICE  OF  MEDICINE 


Tousey's  Medical  Electricity, 
Rontgen   Rays,  and   Radium 

Medical   Electricity,  Rontgen    Rays,  and  Radium.     By 

Sinclair  Tousey,  M.  D.,  Consulting  Surgeon  to  St.  Bar- 
tholomew's Hospital,  New  York.  Octavo  of  1219  pages,  with 
801  illustrations,  19  in  colors.  Cloth,  ^7.50  net;  Half 
Morocco,  $9.00  net. 

NEW  (2d)  EDITION,  RESET 

The  revision  for  this  edition  was  extremely  heavy  ;  new  matter  has  increased 
the  size  of  the  book  by  some  100  pages.  About  50  new  illustrations  have  been 
added.  The  new  matter  added  includes  :  Diathermy,  sinusoidal  currents, 
radiography  with  intensifying  screens,  rontgenotherapy,  the  Coolidge  and 
similar  Rontgen  tubes  and  the  author's  method  of  dosage,  and  radium  therapy. 
The  book  has  been  enriched  by  including  several  of  Machado's  tabular 
classifications  of  electric  methods,  effects,  and  uses. 

Throughout  the  entire  work  everything  concerning  electricity,  jr-rays,  and 
radium  in  medicine,  as  well  as  phototherapy,  is  explained  in  detail — nothing 
is  omitted.  It  tells  you  how  to  equip  your  office,  and,  more  than  that,  how  to 
use  your  apparatus,  explaining  away  all  difficulties.  It  tells  you  just  how  to 
apply  these  measures  in  the  treatment  of  disease.  The  chapters  on  dental 
radiography  are  particularly  valuable  to  those  interested  in  dental  work. 


Abbott's  Medical  Electricity 

Medical  Electricity.  By  George  Knapp  Abbott, 
M.  D.,  Dean  and  Professor  of  Physiologic  Therapy  and 
Practice,  College  of  Medical  Evangelists,  Lonia  Linda,  Cali- 
fornia.    i2mo  of  132  pages,  illustrated.     Cloth,  ^1.25  net. 

This  new  work  gives  the  nurse  the  essentials  of  this  subject.  Dr. 
Abbott's  style  has  made  the  difficult  simple.     The  text  is  illustrated. 


SAUNDERS'  BOOKS  ON 


Gant's  Work  on  Diarrhea 

Diarrhea,  Inflammatory  and  Parasitic  Diseases  of  the 
Gastrointestinal  Tract.    By  Samuel  G.  Gant,  M.  D.,  LL.D.j 

Professor  of  Diseases  of  the  Sigmoid  Flexure,  Colon,  Rectum, 
and  Anus,  New  York  Post-Graduate  Medical  School  and  Hospital. 
Octavo  of  604  pages,  with  181  illustrations.     Cloth,  j^6.oo  net; 

Half  Morocco,  ^7.50  net. 

ILLUSTRATED 

This  new  work  is  particularly  full  on  the  two  practical  phases  of  the  subject 
— diagnosis  and  treatment.  For  instance  :  While  the  essential  diagnostic 
points  are  given  under  each  disease,  a  fuller  description  of  diagnostic  methods 
is  given  in  a  special  chapter.  The  differential  diagnosis  of  diarrheas  of  local 
and  those  of  systematic  disturbances  is  strongly  brought  out.  There  is  a 
special  chapter  on  nervous  diarrheas  and  those  originating  from  gastrogenic 
and  enter ogenic  dyspepsias.  You  get  the  psychotherapy  of  psychic  diarrheas. 
You  get  reliable  methods  of  simultaneously  controlling  associated  constipation 
and  diarrhea.  You  get  a  c(ycc\^^\t.\.^  formulary — prescriptions  from  Dr.  Gant's 
own  practice.  There  is  a  chapter  on  hookworms,  tapeworms  and  round 
worms,  and  on  the  diarrheas  caused  by  them  and  other  parasites.  This  chap- 
ter contains  many  excellent  illustrations.  The  limitations  of  drugs  are  pointed 
out,  the  dangers  of  their  use  emphasized,  and  the  indications  for  surgical 
intervention  given.  You  get  the  technic  in  detail  of  all  surgical -procedures 
indicated — fully  illustrated. 


Gant's  Intestinal  Stasis  (Constipation  and  Obstruction) 

This  work  is  medical,  non-medical  (mechanical),  and  surgical,  the  lat- 
ter really  being  a  complete  work  on  rectocolonic  surgery.  The  chapters 
on  therapeutic  gymnastics  and  massage  are  the  outgrowth  of  Dr.  Gant's 
personal  experience.  You  get  practical  articles  on  diverticulitis,  peri- 
diverticulitis, pericolitis,  perisigmoiditis  {Jackson's  mojibrane),  Lane's 
kink,  and  affections  of  the  ileocecal  valve. 

Octavo  of  575  pages,  with  250  illustrations.  By  Samuel  G.  Gant,  M.  D.,  LL.  D., 
New  York  Post-Graduate  Medical  School  and  Hospital.  Cloth,  ;g6.oo  net ;  Half 
Morocco,  ^7.50  net. 

"The  best  and  most  complete  treatise  on  these  subjects." — Medical 

Record. 


D/AGA'OS/S  AND    TKEATMEN'r 


Cabot's  Differential  Diagnosis 

Differential  Diagnosis.  Presented  through  an  analysis  of 
385  Cases.  By  Richard  C.  Cabot,  M.D.,  Assistant  Professor  of 
Clinical  Medicine,  Harvard  Medical  School.  Two  octavos  of 
750  pages  each,  illustrated.  Per  volume  :  Cloth,  $5.50  net;  Half 
Morocco,  ^7.00  net. 

VOLUME  I  [New  (3d)  Edition — Just  Out]  :  Headache,  pain  in  various 
regions,  fevers,  chills,  coma,  convulsions,  weakness,  cough,  vomiting,  hema- 
turia, dyspnea,  jaundice,  and  nervousness — 21  symptoms  and  385  cases. 

VOLUME  2  f  Just  Out):  Abdominal  and  other  tumors,  vertigo,  diarrhea, 
dyspepsia,  hematemesis,  enlarged  glands,  blood  in  stools,  swelling  of  face, 
hemoptysis,  edema  of  legs,  frequent  micturition  and  polyuria,  fainting,  hoarse- 
ness, pallor,  swelling  of  arm,  delirium,  palpitation  and  arhythmia,  tremor, 
ascites  and  abdominal  enlargement — 19  symptoms  and  317  cases. 


Morrow's  Diag(nostic  and 
Therapeutic   Technic 

Diagnostic  and  Ttierapeutic  Technic.  By  Albert  S. 
Morrow,  M.D.,  Adjunct  Professor  of  Surgery,  New  York  Poly- 
clinic. Octavo  of  830  pages,  with  860  original  line  drawings. 
Cloth,  ^5.00  net. 

NEW  (2d)  EDITION!^ 

Dr.  Morrow's  new  edition  is  decidedly  a  work  for  you — the  physician  en- 
gaged in  general  practice.  It  is  a  work  you  need  because  it  tells  you  just 
how  to  perform  those  procedures  required  of  you  every  day,  and  it  tells  you 
and  shows  you  by  clear,  Wc'tcline-drawings,  in  a  way  never  before  approached. 
The  information  it  gives  is  such  as  you  need  to  know  every  day — transfusion 
and  infusion,  hypodermic  medication,  Bier's  hyperemia,  exploratory  punc- 
tures, aspirations,  anesthesia,  etc. 

Journal  American  Medical  Association 

"  The  procedures  described  are  those  which   practitioners  may  at  some  time  be  called 
on  to  perform." 


SAUNDERS'  BOOKS  ON 


Garrison's  History  of  Medicine 

History  of  Medicine.  With  Medical  Chronology,  Biblio- 
graphic Data,  and  Test  Questions.  By  Fielding  H.  Garrison, 
M.  D.,  Principal  Assistant  Librarian,  Surgeon-General's  Office, 
Washington,  D.  C.  Octavo  of  763  pages,  illustrated.  Cloth, 
$6.00  net ;  Half  Morocco,  ^7.50  net. 

THE  BAEDEKER  OF  MEDICAL  HISTORY 

The  work  begins  with  ancient  and  primitive  medicine,  and  carries  you  in 
a  most  interesting  and  instructive  way  on  through  Egyptian  medicine,  Sumerian 
and  Oriental  medicine,  (Ireek  medicine,  the  Byzantine  period;  the  Mohamme- 
dan and  Jewish  periods,  the  Medieval  period,  the  period  of  the  Renaissance, 
the  Revival  of  learning  and  the  Reformation  ;  the  Seventeenth  Century  (the 
age  of  individual  scientific  endeavor),  the  Eighteenth  Century  (the  age  of 
theories  and  systems),  the  Nineteenth  Century  (the  beginning  of  organized  ad- 
vancement of  science),  the  Twentieth  Century  (the  beginning  of  organized 
preventive  medicine).  You  get  all  the  important  facts  in  medical  history;  a 
biographic  dictionary  of  the  makers  of  medical  history,  arranged  alphabetically; 
an  album  of  medical  portraits;  a  complete  medical  chronology  (data  on  dis- 
eases, drugs,  operations,  etc. );  a  brief  survey  of  the  social  and  cultural  phases 
of  each  period. 


McKenzie  on  E^xercise 


Second 
Edition 


Exercise  in  Education  and  Medicine,  By  R.  Tait 
McKenzie,  B.  A.,  M.  D.,  Professor  of  Physical  Education,  and 
Director  of  the  Department,  University  of  Pennsylvania.  Oc- 
tavo of  585  pages,  with  478  illustrations.      Cloth,  1^4.00  net. 

D.  A.  Sarg^ent,  M.  D.,  Director  of  Hemenivay  Gymnasium,  Harvard  University. 

"  It  carinot  fail  to  be  helpful  to  practitioners  in  medicine.  The  classification  of  athletic 
g'ames  and  exercises  in  tabular  form  for  different  ages,  sexes,  and  occupations  is  the  work  of 
an  expert.     It  should  be  in  the  hands  of  every  physical  educator  and  medical  practitioner." 


Carter's  Diet  Lists 

Diet  Lists  of  the  Presbyterian  Hospital  of  New  York  City. 
Compiled,  with  notes,  by  Herbert  S.  Carter,  M.  D.  i2mo  of  129 
pages.      Cloth,  ;^i.oo  net. 

Bonney's  Tuberculosis  second  Edition 

Tuberculosis.  By  Sherman  G.  Bonney,  M.D.,  Professor  of 
Medicine,  Denver  and  Gross  College  of  Medicine.  Octavo  of  955  pages, 
with  243  illustrations.     Cloth,  $7.00  net ;  Half  Morocco,  %'i.^o  net. 


THE    PRACTICE    OF   MEDICINE 


Anders* 
Practice    of    Medicine 

A  Text=Book  of  the  Practice  of  Medicine.  By  James 
M.  Anders,  M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  the  Practice 
of  Medicine  and  of  Clinical  Medicine,  Medico-Chirurgical  Col- 
lege, Philadelphia.  Handsome  octavo,  1332  pages,  fully  illus- 
trated.    Cloth,  ^5.50  net ;  Half  Morocco,  $7.00  net. 

NEW  (I2th)   EDITION 

The  success  of  this  work  is  no  doubt  due  to  the  extensive  consideration 
given  to  Diagnosis  and  Treatment,  under  Differential  Diagnosis  the  points  of 
distinction  of  simulating  diseases  being  presented  in  tabular  form.  In  this 
new  edition  Dr.  Anders  has  included  all  the  most  important  advances  in 
medicine,  keeping  the  book  within  bounds  by  a  judicious  elimination  of 
obsolete  matter.      A  great  many  articles  have  also  been  rewritten. 

Wm.  E.  Quine,   M.  D.,    College  of  Physicians  and  Stirgeons,  Chicago. 

"  I  consider  Anders'  Practice  one  of  the  best  single-volume  works  before  the  profession 
at  this  time,  and  one  of  the  best  text-books  for  medical  students." 


DaCost&'s  Physical  Diagnosis 

Pliysical  Diagnosis.  By  John  C.  DaCosta,  Jr.,  Asso- 
ciate Professor  of  Medicine,  Jefferson  Medical  College.  Octavo 
of  589  pages,  with  original  illustrations.     Cloth,  $3.50  net. 

NEW  (3d)  EDITION 

In  Dr.  DaCosta's  work  every  method  given  has  been  carefully  tested  and 
proved  of  value  by  the  author  himself.  Nonnal  physical  signs  are  explained 
in  detail  in  order  to  aid  the  diagnostician  in  determining  the  abnormal.  Both 
direct  and  differential  diagnoses  are  emphasized.  The  243  original  illustra- 
tions are  artistic  as  well  as  practical. 

Henry  L.  Eisner,   M.  D.,   Professor  of  Medicine,  Syracuse  University. 

"  I  have  reviewed  this  book  and  am  thoroughly  convinced  that  it  is  one  of  the  best 
ever  written  on  the  subject.     In  every  way  I  findit  a  superior  production." 


SAUNDERS'    BOOKS   ON 


Sahli's  Diag(nostic  Methods 

Edited  by  Nath'l  Bowditch  Potter,   M.D. 


A  Treatise  on  Diagnostic  Methods  of   Examination. 

By  Prof.  Dr.  H.  Sahli,  of  Bern.  Edited,  with  additions,  by 
Nath'l  Bowditch  Potter,  M.D.,  Assistant  Professor  of  Clinical 
Medicine,  Columbia  University.  Octavo  of  1225  pages,  pro- 
fusely illustrated.     Cloth,  $6.50  net. 

SECOND  EDITION,  RESET 
Lewellys  F.  Barker,  M.  D. 

Professor  of  Mt'dicine,  Johns  Hopkins  University 
"  I  am  delighted  with  it,  and  it  will  be  a  pleasure  to  recommend  it  to  our  students  in 
the  Johns  Hopkins  Medical  School." 


Friedenwald  (^  Ruhrah  on  Diet 

Diet  in  Health  and  Disease.  By  Julius  Friedenwald, 
M.  D.,  Professor  of  Diseases  of  the  Stomach,  and  John  Ruhrah, 
M.  D.,  Professor  of  Diseases  of  Children,  College  of  Physicians 
and  Surgeons,  Baltimore.   Octavo  of  85  7  pages.     Cloth,  ^4.00  net. 

NEW  (4th)  EDITION 

Dietetic  management  in  all  diseases  in  which  diet  plays  a  part  in  treat- 
ment is  carefully  considered,  the  articles  on  diet  in  diseases  of  the  digestive 
organs  containing  numerous  diet  lists  and  explicit  instructions  for  administra- 
tion. The  feeding  of  infants  and  children,  of  patients  before  and  after  anes- 
thesia and  surgical  operations,  are  all  taken  up  in  detail. 

"  It  seems  to  me  that  you  have  prepared  the  most  valuable  work  of  the  kind  now  avail- 
able. I  am  especially  glad  to  see  the  long  list  of  analyses  of  diflferent  kinds  of  food." — 
George  Dock,  M.  D.,  Tidane  University  of  Louisiana. 


Eggleston's  Prescription  Writing 

This  new  work  is  a  crystallization  of  Dr.  Eggleston's  long  experience 
in  teaching  this  subject.  It  covers  the  entire  field  in  a  most  practical  way, 
taking  up  grammar,  construction,  dosage,  vehicles,  incompatibility,  ad- 
ministration, etc. 

i6mo  of  115  pages.      By  Gary  Eggleston,   M.  D.,  Instructor  in  Pharmacology  at 
Gornell  Univeisity  Medical  School.      Gloth   ;^i.oo  net. 


PRACTICE  OF  MEDICINE 


Kemp  on  Stomach, 
Intestines,  and  Pancreas 

Diseases   of   the   Stomach,   Intestines,    and    Pancreas. 

By  Robert  Coleman  Kemp,  M.  D.,  Professor  of  Gastro-intes- 
tinal  Diseases  at  the  New  York  School  of  Clinical  Medicine. 
Octavo  of  1025  pages,  with  377  illustrations.  Cloth,  $6.50  net; 
Half  Morocco,  $8.00  net. 

NEW  (2d)  EDITION 

It  is  the  practitioner  who  first  meets  with  these  cases,  and  it  is  he  upon 
whom  the  burden  of  diagnosis  rests.  After  the  diagnosis  is  established,  the 
practitioner,  if  properly  equipped,  could  frequently  treat  the  case  himself 
instead  of  transferring  it  to  a  specialist.  This  work  is  intended  to  equip  the 
practitioner  with  this  end  in  view. 

The  Therapeutic  Gazette 

"The  therapeutic  advice  which  is  ^ven  is  excellent.  Methods  of  physical  and 
chemical  examination  are  adequately  and  correctly  described." 


Dastedo's  IVlateria  Medica,  Pharmacology, 
Therapeutics,  and     Prescription      i^riting 

By  W.  A.  Bastedo,  M.  D.,  Associate  in  Pharmacology  and 
Therapeutics  at  Columbia  University.  Octavo  of  602  pages, 
illustrated.  Cloth,  $3.50  net. 

THREE  PRINTINGS  IN  Sl^.  MONTHS 

Dr.  Bistedo's  new  work  has  the  distinct  advantage  of  presenting  the 
subjects  from  both  the  laboratory  and  the  clinical  sides.  Dr.  Bastedo  for 
many  years  devoted  his  entire  time  to  laboratory  work.  Now,  however,  he 
is  strictly  a  clinical  m2,\\.  He  gives  you  the  practical,  daily  application  of  that 
information  he  gleaned  at  first  hand  in  the  laboratory^ — facts  you  can  use  ir. 
your  bedside  practice.  Because  of  this  early  laboratory  training  you  are 
assured  that  his  book  is  correct  according  to  laboratory  standards.  Being 
now  a  strictly  clinical  man,  you  know  that  his  book  is  modeled  with  the  common 
purpose  of  all  medical  practice  :    The  treat77ient  of  the  sick. 


lo  SAUNDERS'    BOOKS    ON 

Faught*s  Blood-Pressure 

Blood=Pressure   from    the    Clinical    Standpoint.      By 

Francis  A.  Fau(;ht,  M.  D.,  formerly  Director  of  the  Laboratory 
of  Clinical  Medicine  of  the  Medico-Chirurgical  College  of  Phila- 
delphia.    Octavo  of  475  pages,  illustrated. 

NEW   (2d)   EDITION 

Dr.  Faught's  book  is  designed  for  practical  help  at  the  bedside.  It  meets 
the  urgent  needs  of  the  general  practitioner,  who  heretofore  had  no  book  to 
which  to  turn  in  case  of  emergency.  Every  effort  has  been  made  to  provide 
here  a  practical  guide,  full  of  information  of  a  clinical  nature,  and  presented 
in  a  way  readily  available  for  daily  use  by  the  busy  man.  Besides  the  actual 
technic  of  using  the  sphygmomanometer  in  diagnosing  disease,  Dr.  Faught 
has  included  a  brief  general  discussion  of  the  process  of  circulation.  The 
practical  application  of  sphygmomanometric  findings  within  recent  years  makes 
it  imperaiive  for  every  medical  man  to  have  close  at  hand  an  up-to-date  work 
on  this  subject, 

Anders  and  Boston's  Medical 

Diagnosis 

A  Text-Book  of  Medical  Diagnosis.  By  James  M.  An- 
ders, M.D.,  Ph.D.,  LL.  D.,  Professor  of  the  Theory  and  Prac- 
tice of  Medicine  and  of  Clinical  Medicine,  and  L.  Napoleon 
Boston,  M.  D.,  Professor  of  Physical  Diagnosis,  Medico-Chirur- 
gical College,  Philadelphia.  Octavo  of  1248  pages,  with  466 
illustrations.     Cloth,  ^6.00  net. 

NEW  (2d)  EDITION 

This  new  worl<:  is  designed  expressly  for  the  general  practitioner.  The 
methods  given  are  practical  and  especially  adapted  for  quick  reference.  The 
diagnostic  methods  are  presented  in  a  forceful,  definite  Way  by  men  who  have 
had  wide  experience  at  the  bedside  and  in  the  clinical  laboratory. 

The  Medical  Record 

"  The  association  in  its  authorship  of  a  celebrated  cHnician  and  a  well-known  labora- 
tory worker  is  most  fortunate.      It  must  long  occupy  a  pre-eminent  position." 


PRACTICE  OF  MEDICINE  ii 


Deaderick  ^  Thompson's  Endemic  Diseases  of  South 

Enkemic  Diseases  of  the  Southern  Siates.  By  ^VILI,IAM 
II,  Deaderick,  M.  D.,  Member  American  Society  of  Tropical  Medicine; 
and  LoYD  Thompson,  M.  D.,  Charter  Member  American  Associaiioii  of 
Immunologists.  Octavo  of  546  pages,  illustrated.  Cloth,  $5.00  net ; 
Half  Morocco,  $6.50  net. 

This  new  work  is  really  a  collection  of  monographs  on  malaria,  blackwater  fever, 
pellagra,  amebic  dysentery,  hookworm  disease,  and  other  intestinal  parasites. 
Diagnosis,  prophylaxis,  and  treatment  are  gone  into  in  detail,  giving  you  every  aid  to 
the  correct  interpretation  of  the  symptoms  presented,  and  every  modern  means  of 
value  in  the  prevention  and  treatment  of  the  diseases  discussed. 


Smith's  What  to  Eat  and  Why  Second  Edition 

What  to  Eat  and  Why.  By  G.  Carroll  Smith,  M.  D.,  Boston. 
1 2mo  of  377  pages.      Cloth,  ^2.50  net. 

With  this  book  you  no  longer  need  send  your  patients  to  a  specialist  to  be  dieted — 
you  will  be  able  to  prescribe  the  suitable  diet  yourself,  just  as  you  do  other  forms  of 
therapy.  Dr.  Smith  gives  'the  why"  of  each  statement  he  makes.  It  is  this  knowing 
why  which  gives  you  confidence  in  the  book,  which  makes  you  feel  that  Dr.  Smith 
knozvs. 


Ward's  Bedside  Hematology 

Bedside  Hematology.      By  Gordon  R.  Ward,  M.  D,,    Fellow   of 
the  Royal  Society  of  Medicine,    London.    England,        Octavo   of  394 

pages,  illustrated.     Cloth,  ^3.50  net. 


Slade's  Physical  Examination  {j3  Diagnostic  Anatomy 

Phy'sical  Examination  and  Diagnostic  Anatomy.  By  Charles 
B.  Slade,  M.  D.,  Chief  of  Clinic  in  General  Medicine,  University  and 
Bellevue  Hospital  Medical  College,  i2mo  of  146  pages,  illustrated. 
Cloth,  31-25  net. 


12  SAUNDERS'    BOOKS  ON 

Stevens*  Therapeutics  Fi^*J»  Edition 

A  Text-Book  of  Modern  Materia  Medica  and  Therapeutics. 
By  A.  A.  Stevens,  A.M.,  M.D.,  Lecturer  on  Physical  Diagnosis  in  the 
University  of  Pennsylvania.     Octavo  of  675  pages.      Cloth,  ^3.50  net. 

Dr  Stevens'  Therapeutics  is  one  of  the  must  successful  works  on  the  subject  ever 
published.  In  this  new  edition  the  work  has  undergone  a  very  thorough  revision, 
and  now  represents  the  very  latest  advances. 

The  Medical  Record,  New  York 

"  Among  the  numerous  treatises  on  this  most  important  branch  of  medical  practice, 
this  by  Dr.  Stevens  has  ranked  with  the  best." 

Sutler's  Materia  Medica  Sixth  Edition 

A  Text-Book  of  Materia  Meuica,  Therapeutics,  and  Pharma- 
cology. By  George  Y.  Butler,  Ph.G.,  M.D.,  Professor  and  Head 
of  the  Department  of  Therapeutics  and  Professor  of  Preventive  and 
Clinical  Medicine,  Chicago  College  of  Medicine  and  Surgery,  Medical 
Department  Valpariso  University.  Octavo  of  702  pages,  illustrated. 
Cloth,  ^4.00  net;  Half  Morocco, ^5. 5Q_ net. 

For  this  sixth  edition  Dr.  Butler  has  entirely  remodeled  his  work,  a  great  part  hav- 
ing been  rewritten.  All  obsolete  matter  has  been  eliminated,  and  special  attention 
has  been  given  to  the  toxicologic   and  therapeutic  effects  of  the  newer  compounds. 

Medic&l  Record,  New  York 

"  Nothing  has  been  omitted  by  the  author  which,  in  his  judgment,  would  add  to 
the  completeness  of  the  text." 

SoUmann's  Pharmacology  Second  Edition 

A  Text-Book  of  Pharmacology.  By  Torald  Sollmann,  M.D., 
Professor  of  Phafmacology  and  Materia  Medica,  Western  Reserve  Uni- 
versity.    Octavo  of  1070  pages,  illustrated.     Cloth,  ^4.00  net. 

The  author  bases  the  study  of  therapeutics  on  systematic  knowledge  of  the  nature 
and  properties  of  drugs,  and  thus  brings  out  forcibly  the  intimate  relation  between 
pharmacology  and  practical  medicine. 

J.  F.  Fotheringham,  M.D.,  Trinity  Medical  College,   Toronto. 

"The  work  certainly  occupies  ground  not  covered  in  so  concise,  useful,  and  scien- 
tific a  manner  by  any  other  text  I  have  read  on  the  subjects  embraced." 

Arny*s  Pharmacy 

Principles  of  Pharmacy.  By  Henry  V.  Arny,  Ph.  G.,  Ph.  D., 
professor  of  Pharmacy,  New  York  College  of  Pharmacy.  Octavo  of 
1 1 75  pages,  with  246  illustrations.      Cloth.  ^5.00  net. 

George  Reimann,  Ph.  G.,  Secretary  of  the  New  York  state  Board  0/  Pharmacy. 

"  I  would  say  that  the  book  is  certainly  a  great  help  to  the  student,  and  I  think  it 
ought  to  be  in  thehands  of  every  person  who  is  contemplating  the  study  of  pharmacy." 


THERAPEUTICS  AND  MATERIA  MEDICA  13 


Hinsdale's   Hydrotherapy 

Hydrotherapy  :  A  Treatise  on  Hydrotherapy  in  General ; 
Its  Application  to  Special  Affections ;  the  Technic  or  Processes 
Employed,  and  the  Use  of  Waters  Internally.  By  Guy  Hinsdale, 
M.  D.,  P»lo\v  of  the  Royal  Society  of  Medicine  of  Great  Britain. 
Octavo  of  466  pages,  illustrated.       Cloth, $3. 50  net. 

The  Medical  Record 

"  We  cannot  conceive  of  a  work  more  useful  to  the  general  practitioner  than  this,  nor 
one  to  which  he  would  resort  more  frequently  for  reference  and  guidance  in  his  daily 
work." 


Kelly's  Cyclopedia  of  American 
Medical  Biography 

Cyclopedia  of  American  Medical  Biography.  By  How- 
ard A.  Kelly,  M.  D.  ,  Johns  Hopkins  University.  Two  octavos 
of  525  pages  each,  with  portraits.  Per  set:  Cloth,  $10.00  net; 
Half  Morocco,  ^13.00  net. 

Dr.  Kelly,  in  these  two  handsome  volumes,  presents  concise,  yet  com- 
plete biographies  of  those  men  and  women  who  liave  contributed  notewor- 
thily  to  the  advancement  of  medicine  in  America.  Dr.  Kelly's  reputation  for 
painstaking  care  assures  accuracy  of  statement.  There  are  about  one  thousand 
biographies  included. 

Swan's  Prescription-writing  and  Formulary 

Prescription-writing  and  Formulary.  By  John  M.  Swan, 
M.D.,  Director  Glen  Springs  Sanitarium,  Watkins,  N.  Y.  l2mo  of  185 
pages.      Flexible  cloth,  $1.25  net. 

Stewart's    Pocket    Therapeutics    and    Dose- 
book  New  (4th)  Edition 
Pocket  Therapeutics  and  Dose-book.     By  Morse  Stewart,  Jr., 
M.D.     32mo  of  263  pages.      Cloth,  ^i. 00  net. 

Bohm  and  Painter's  Massage 

Massage.  By  Max  Bohm,  M.  D.,  of  Berlin,  Germany.  Edited, 
with  an  Introduction,  by  Charles  F.  Painter,  M.  D.,  Professor  of 
Orthopedic  Surgery  at  Tufts  College  Medical  School,  Boston.  Octavo 
of  91  pages,  with  97  ^r^^r/iVa/ illustrations.     Cloth,  ^1.75  net. 


14  SAUNDERS'    BOOKS    ON 

THE  BEST  /imeriCoIl  STANDARD 

Illustrated   Dictionary 

The  New  (8th)    Edition.  Reset 

The  American  Illustrated  Medical  Dictionary.     By  W.  A. 

Newman  Borland,  M.  D.,  Editor  of  ^'The  American  Pocket 
Medical  Dictionary."  Octavo  of  1 137  pages.  Flexible  leather, 
^4.50  net;  with  thumb  index,  ;^5.oo  net. 

OVER   1500  NEW  WORDS 

Howard   A.    Kelly,    M.  D.,  Johns  Hopkins  University ,  Baltimore. 

"  Dr.  Dorland's  dictionary  is  admirable.      It  is  so  well  gotten  up  and  of  such  conve- 
nient size.     No  errors  have  been  found  in  my  use  of  it." 


Thornton's  Dose-Book  Fourth  Edition 

Dose-Book  and   Manual  of   Prescription-Writing.     By  E.  Q. 

Thornton,  M.  D.,  Assistant   Professor  of  Materia    Medica,    Jefferson 

Medical    College,    Philadelphia.       Post-octavo,    392    pages,    illustrated. 

Flexible  leather,  ^2.00  net. 

"  It  will  afford  me  much  pleasure  to  recommend  the  book  to  my  classes,  who  oftep 
fail  to  find  such  information   in    their    other    text-books." — C.    H.    Miller,    M.D 
Professor  of  Pharmacology,    Northwestern  University  Medical  School,  Chicago. 

Lusk    on    Nutrition  second  Edition 

Elements  of  the  Science  of  Nutrition.  By  Graham  Lusk, 
Ph.D.,  Professor  of  Physiology  in  Cornell  University  Medical  School. 
Octavo  of  402  pages.     Cloth,  ^3.00  net. 

"  I  shall  recommend  it  highly.  It  is  a  comfort  to  have  such  a  discussion  of  the 
subject."— Lewellvs  F.  Barker,  M.  D.,  Professor  of  the  Principles  and  Practice 
of  Medicine,  Johns  Hopkins  University, 

Hatcher  and  SoUmann's  Materia  Medica 

A  Text-Book  of  Materia  Medica  :  including  Laboratory  Exer- 
cises in  the  Histologic  and  Chemic  Examination  of  Drugs.  By  Robert 
A.  Hatcher,  Ph.  G.,  M.  D.  ;  and  Torald  Sollmann,  M.  D.  i2mo 
of  411  pages.     Flexible  leather,  ^2.00  net. 


Bridge  on  Tuberculosis 


Tuberculosis.     By  Norman  Bridge,  A.  M.,  M.  D.     i2mo  of  302 
pages,  illustrated.     Cloth,  ^\  .50  net. 


MATERIA  ME  Die  A  AND   THERAPEUTICS.  15 

American  Pocket  Dictionary  ^ew  (9th)  Edition 

The  Amkrican  Pocket  Medical  Dictionary.  Edited  by  W. 
A.  Newman  Dorlano,  M.D.  Flexible  leather,  with  gold  edges,  ^i.oo 
net ;  with  thumb  index,  $1.25  net. 

Pusey  and  Caldwell  on  X-Rays  Second  Edition 

The  Practical  Application  of  the  Rontgen  Rays  in  Thera- 
peutics AND  Diagnosis.  By  William  Allen  Pusey,  A.  M.,  M.  D,, 
and  Eugene  W.  Caldwell,  B.  S.  Octavo  of  625  pages,  with  200 
illustrations.     Cloth,  $5.00  net. 

Cohen   and   Eshner's    Diagnosis.     Second  Revised  Edition 

Essentials  of  Diagnosis.  By  S.  Solis-Cohen,  M.  D.,  and  A.  A. 
Eshner,  M.  D.  Post-octavo,  382  pages  ;  55  illustrations.  Cloth,  ^i.oo 
net.      In  Sazinders'   Question- Compend  Series, 

Seventh 

Morris'  Materia  Medica  and  Therapeutics         Edition 

Essentials  of  Materia  Medica,  Therapeutics,  and  Prescrip- 
tion-Writing, By  Henry  Morris,  M.  D.  Revised  by  W.  A.  Bas- 
TEDO,  M.  D.,  Instructor  in  Materia  Medica  and  Pharmacology,  Columbia 
University.     l2mo,  300  pages.      Cloth,  ^i. 00  net.    Sanndeis'  Compends. 

Deaderick  on  Malaria 

Practical  Study  of  Malaria.  By  William  H.  Deaderick, 
M.  D.,  Member  American  Society  of  Tropical  Medicine.  Octavo  of 
402  pages,  illustrated.     Cloth,  $4.50  net. 

Goepp's  State  Board  Questions  Third  Edition 

State  Board  Questions  and  Answers.  By  R.  Max  Goepp, 
M.  D.,  Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.  Octavo 
of  715  pages.     Cloth,  ^4.00  net. 

Niles  on   Pellagra  New  (2d)  Edition 

Pellagra.  By  George  M.  Niles,  M.  D.,  Gastro-enterologist  to 
the  Georgia  Baptist  Hospital,  Atlanta.  Octavo  of  253  pages,  illustrated. 
Cloth,  ^3.00  net. 

Arnold's  Medical  Diet  Charts 

Medical  Diet  Charts.  Prepared  by  H.  D.  Arnold,  m.  D,, 
Professor  of  Clinical  Medicine,  Tufts  Medical  College,  Boston.  Single 
charts,  5  cents;  50  charts,  ;^2.oo  net;  500  charts,  ^18.00  net;  looo 
charts,  $30.00  net. 


1 6  SAUNDERS'    BOOK'S    ON   PRACTICE,   Etc. 


Saunders*   Pocket   Formulary  Ninth  Edition 

Saunders'  Pocket     Medical    Formulary,      liy    William     M. 

Powell,    j\I.  D.       Containing   1900    formulas    from    the    best-known 

authorities.  In    flexible    leather,    with    side    index,    wallet,    and   flap. 
$1.75  net. 

Jakob  and  Eshner's  Internal  Medicine  and  Diagnosis 

Atlas  and  Epitome  of  Internal  Medicine  and  Clinical  Diag- 
nosis. By  Dr.  Chr.  Jakob,  of  Erlangen.  Edited,  with  additions,  by 
A.  A.  Eshner,  M.  D.  182  colored  figures  on  68  plates,  64  text-cuts, 
259  pages  of  text.     Cloth,  $3.00  net.      In  Smindei  s'  Hand-Atlas  Series. 

Lockwood's  Practice  of  Medicine    RevUef^'EnWeS 

A  Manual  of  the  Practice  of  Medicine.  By  Geo.  Roe  Lock- 
wood,  M.  D.,  Attending  Physician  to  the  Bellevue  Hospital,  New  York 
City.     Octavo,  847  pages,  illustrated.     Cloth,  ^4.00  net. 

Fenwick*s  Dyspepsia 

Dyspepsia.  By  William  Soltau  Fenwick,  M.  D.,  of  London. 
Octavo  of  485  pages,  illustrated.     Cloth,  $3.00  net. 

Jelliffe*s   Pharmacognosy 

An  Introduction  to  Pharmacognosy.  By  Smi ih  Ely  Jelliffe, 
Ph.  D.,  M.  D.,  Columbia  University,  New  York.  Octavo  of  265  pages, 
illustrated.      Cloth,  ^2.50  net. 

Stevens'    Practice   of  Medicine  New  (lOth)  Edition 

A  Manual  of  the  Practice  of  Medicine.  By  A.  A.  Stevens, 
A.  M.,  M.  D.,  Professor  of  Therapeutics  and  Clinical  Medicine,  Woman's 
Medical  College,  Philadelphia.  i2mo,  573  pnges,  illustrated.  Flexible 
leather,  S2.50  net. 

Camac*s  Epoch=Making(  Contributions 

Epoch-making  Contributions  to  Medicine  and  Surgery.  By 
C.  N.  B.  Camac,  M.  D.,  of  New  York  City.  Octavo  of  450  pages, 
with  portraits.     Artistically  bound,  ;^4.oo  net. 

Todd's  Clinical  Diagnosis  New  (3d)  Edition 

Clinical  Diagnosis.  By  James  Campbell  Todd,  MD.  Professor 
of  Pathology,  University  of  Colorado,  Denver.  i2mo  of  585  pages, 
illustrated.     Cloth,  $2.50  net. 


COLUMBIA  UNIVERSITY  LIBRARIES 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing,  as 
provided  by  the  rules  of  the  Library  or  by  special  arrange- 
ment with  the  Librarian  in  charge. 

DATE  BORROWED 

DATEPME 

DATE  BORROWED 

DATE  DUE 

-Ift;  f-;           .♦ 

'■    ''■     7    *y:' 

j 

1 

, 

C28(n4l)M100 

i 
i 

^5^^ 


V^ft*\.wft.\    oW  V^VOi^S^^^^Sg-^ 


